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For hours, travelling roughly on the soggy 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 labour, in agonizing discomfort after her womb tore, but was now being tossed around in the ambulance that bumped over the potholes and ridges of the road through the Chadian desert.

Most of the close to a million Sudanese refugees who have fled to Chad since 2023, living hand to mouth in this harsh landscape, are women. They live in remote settlements in the desert with insufficient supplies, few job opportunities and with healthcare often a life-threateningly long distance away.

The clinic Mohammed needed was in Metche, one more encampment more than 120 minutes away.

“I continuously experienced infections during my gestation and I had to go the medical tent multiple occasions – when I was there, the labour began. But I found it impossible 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 agony; it was so bad I became confused.”

Her maternal figure, Ashe Khamis Abdullah, 40, worried she would suffer the death of her offspring and descendant. But Mohammed was hurried into surgery when she arrived at the hospital and an critical surgical delivery rescued her and her son, Muwais.

Chad previously recorded the world’s second-highest maternal mortality rate before the current influx 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 mostly emergency conditions this year, the doctors are able to rescue numerous, but it is what happens to the women who are fail to get to the hospital that concerns them.

In the couple of years since the internal conflict in Sudan began, the vast majority of the displaced persons who came and settled in Chad are females and minors. 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 hosted the bulk of the millions of people who have run from the war in Sudan; others have gone 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 near homes and land; many were slain, abducted or made to join the conflict. Those of employable age rapidly leave from Chad’s desolate refugee camps to seek employment in the capital, N’Djamena, or beyond, in nearby Libya.

It means women are left alone, without the ability to sustain the dependents left in their responsibility. 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 50,000, but in distant locations with few facilities and few opportunities.

Metche has a hospital set up by a medical aid organization, which was initially a few tents but has expanded to include an surgical room, but not much more. There is unemployment, 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 advised quantity.

This seclusion means hospitals are admitting women with issues in their pregnancy when it is almost too late. There is only a sole emergency vehicle to serve the area between the Metche hospital and the clinic near the Alacha encampment, where Mohammed is one of close to fifty thousand refugees. The medical team has seen cases where women in desperate pain have had to remain overnight for the ambulance to arrive.

Imagine being nine months pregnant, in labour, and travelling hours on a animal-drawn transport to get to a clinic

As well as being bumpy, the path goes through valleys that become inundated during the wet period, completely cutting off travel.

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

“Imagine being nine months pregnant, in labour, and making a long trip on a animal-drawn vehicle to get to a hospital. The biggest factor is the lag but having to come in these conditions also has an impact on the delivery,” says the surgeon.

Undernourishment, which is increasing, also increases the risk of issues in pregnancy, including the uterine splits that medical staff see regularly.

Mohammed has stayed at the medical facility in the couple of months since her caesarean. Suffering from malnutrition, she got sick, while her son has been regularly checked. The parent has journeyed to other towns in look for employment, so Mohammed is entirely leaning on her mother.

The malnutrition ward has increased to six tents and has cases exceeding capacity into other sections. Children are placed under mosquito nets in oppressive temperatures in almost complete silence as medical staff work, preparing treatments and weighing children on a device constructed from a bucket and rope.

In moderate instances children get small bags of PlumpyNut, the uniquely designed peanut paste, but the worst cases need a consistent supply of enriched milk. Mohammed’s baby is administered his nutrition through a injector.

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

“Every day, I see additional kids arriving in this tent,” she says. “The meals we consume is low-quality, there’s insufficient food and it’s not nutritious.

“If we were at home, we could’ve coped better. You can go and grow crops, you can find employment, but here we’re dependent on what we’re provided.”

And what they are allocated is a meager portion of grain, cooking oil and salt, distributed every two months. Such a simple food offers little sustenance, and the meager funds she is given acquires minimal items in the weekly food markets, where costs have risen.

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

Finding no work in Chad, her husband has left for Libya in the hope of raising enough money for them to follow. She resides with his relatives, sharing out whatever meals they acquire.

Abubakar says she has already witnessed food supplies decreasing and there are fears that the abrupt cuts in foreign support money 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