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For a long time, jolting along the flooded dirt track to the hospital, 18-year-old Makka Ibraheem Mohammed gripped firmly to her seat and concentrated on 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 lurched across the uneven terrain of the road through the Chadian desert.

Most of the 878,000 Sudanese people who ran to Chad since 2023, living hand to mouth in this harsh landscape, are females. They stay in secluded encampments in the desert with scarce resources, few job opportunities 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 gestation and I had to go the health post seven times – when I was there, the labour began. But I wasn’t able to give birth without intervention because my uterus had collapsed,” says Mohammed. “I had to wait two hours for the ambulance but all I remember was the pain; it was so intense I became confused.”

Her maternal figure, Ashe Khamis Abdullah, 40, worried she would lose both her offspring and descendant. But Mohammed was immediately taken for surgery when she reached the hospital and an urgent C-section preserved the lives of her and her son, Muwais.

Chad previously recorded the world’s second most severe maternal death rate before the ongoing stream of refugees, but the circumstances suffered by the Sudanese put even more women in danger.

At the hospital, where they have delivered 824 babies in mostly emergency conditions this year, the medical staff are able to rescue numerous, but it is what affects the women who are fail to get to the hospital that alarms the professionals.

In the two years since the internal conflict in Sudan began, 86% of the displaced persons who came and stayed in Chad are women and children. In total, about one point two million Sudanese are being sheltered in the eastern region of the country, a large number of whom fled the earlier war in Darfur.

Chad has accepted the majority 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 11.8 million Sudanese have been forced out of their homes.

Many men have stayed behind to be close to homes and land; some were slain, taken hostage or made to join the conflict. Those of adult age rapidly leave from Chad’s isolated encampments to find work in the main city, N’Djamena, or beyond, in adjacent Libya.

It implies women are left alone, without the means to feed the children and the elderly left in their charge. To avoid overcrowding near the border, the Chadian government has transferred refugees to more compact settlements such as Metche with average populations of about 50,000, but in distant locations with few facilities and few opportunities.

Metche has a hospital built by a medical aid organization, which was initially a few tents but has developed to contain an surgical room, but few additional amenities. There is unemployment, families must journey for extended periods to find fuel, and each person must subsist with about a small amount of water a day – well under the recommended 20 litres.

This isolation means hospitals are receiving women with issues in their pregnancy when it is almost too late. There is only a one medical transport to travel the path between the Metche hospital and the medical tent 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 wait an entire night for the ambulance to arrive.

Imagine being nine months pregnant, in labour, and making a lengthy trip on a donkey-drawn vehicle to get to a clinic

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

A surgeon at the hospital in Metche said each patient she treats is an emergency, with some women having to make challenging travels to the hospital by on foot or on a mule.

“Imagine being nine months pregnant, in delivery, and journeying for an extended time on a donkey cart to get to a clinic. The main problem is the lag but having to arrive under such circumstances also has an impact on the childbirth,” says the surgeon.

Malnutrition, which is on the rise, also increases the risk of issues in pregnancy, including the uterine splits that medical staff frequently observe.

Mohammed has remained in hospital in the 60 days since her surgical delivery. Suffering from malnutrition, she contracted an illness, while her son has been regularly checked. The father has gone 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 individuals overflowing into other sections. Children rest beneath mosquito nets in extreme warmth in almost utter stillness as health workers work, preparing treatments and assessing weights on a scale made from a container and string.

In mild cases children get packets of PlumpyNut, the uniquely designed peanut paste, but the worst cases need a regular intake of fortified formula. Mohammed’s baby is administered his nutrition through a syringe.

Suhayba Abdullah Abubakar’s infant son, Sufian Sulaiman, is being nourished via a nose tube. The infant has been sick for the past year but Abubakar was repeatedly given only painkillers without any medical assessment, until she made the trip from Alacha to Metche.

“Every day, I see additional kids joining us in this shelter,” she says. “The meals we consume is poor, there’s not enough to eat and it’s deficient in vitamins.

“If we were at home, we could’ve adjusted our lives. You can go and grow crops, you can work to earn some money, but here we’re relying on what we’re provided.”

And what they are given is a small amount of sorghum, cooking oil and salt, handed out every two months. Such a simple food offers little sustenance, and the meager funds she is given cannot buy much in the local bazaars, where values have increased.

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

Failing to secure jobs in Chad, her spouse has left for Libya in the desire to gathering adequate cash for them to come later. She resides with his kin, sharing out whatever meals they acquire.

Abubakar says she has already witnessed 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 worsen the situation. Despite the war in Sudan having created the 21st century’s gravest emergency and the {scale of needs|extent