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For an extended period, travelling roughly on the soggy dirt track to the hospital, 18-year-old Makka Ibraheem Mohammed held on tight to her seat and focused on stopping herself throwing up. She was in childbirth, in severe suffering after her womb tore, but was now being shaken violently in the ambulance that lurched across 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, surviving precariously in this difficult terrain, are females. They live in remote settlements in the desert with insufficient supplies, little employment and with healthcare often a life-threateningly long distance away.

The medical center Mohammed needed was in Metche, another refugee camp more than 120 minutes 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 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 agony; it was so bad I became confused.”

Her parent, Ashe Khamis Abdullah, 40, was terrified she would suffer the death of her offspring and descendant. But Mohammed was rushed straight into surgery when she arrived at the hospital and an urgent C-section saved her and her son, Muwais.

Chad already had the world’s second-highest maternal mortality rate before the recent arrival of refugees, but the situations faced by the Sudanese expose further women in danger.

At the hospital, where they have birthed 824 babies in frequently urgent circumstances this year, the doctors are able to rescue numerous, but it is what occurs with the women who are fail to get to the hospital that alarms the professionals.

In the two years since the civil war in Sudan started, 86% of the people who reached and settled in Chad are females and minors. In total, about one point two million Sudanese are being accommodated in the eastern region of the country, four hundred thousand of whom escaped the earlier war in Darfur.

Chad has accepted the majority of the millions of people who have run from the war in Sudan; some have travelled to South Sudan, Egypt and Ethiopia. A total of millions of Sudanese have been displaced from their homes.

Many men have not left to be close to homes and land; some were slain, abducted or conscripted. Those of employable age move on quickly from Chad’s barren settlements to look for jobs in the capital, N’Djamena, or further, in neighbouring Libya.

It means women are abandoned, without the means to provide for the dependents left in their care. 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 a large community, but in remote areas with few facilities and minimal chances.

Metche has a hospital established by a medical aid organization, which began as a few tents but has developed to contain an operating theatre, but not much more. There is a lack of jobs, families must walk hours to find fuel, and each person must subsist with about nine litres of water a day – well under the suggested amount.

This seclusion means hospitals are receiving women with issues in their pregnancy dangerously late. There is only a single ambulance to travel the path between the Metche hospital and the health post near the Alacha encampment, where Mohammed is one of a large number of refugees. The medical team has encountered situations where women in severe suffering have had to remain overnight for the ambulance to arrive.

Imagine being nine months pregnant, in labour, and travelling hours on a cart pulled by a donkey to get to a hospital

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

A surgeon at the hospital in Metche said all the situations she encounters is an crisis, with some women having to make arduous trips to the hospital by on foot or on a donkey.

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

Malnutrition, which is increasing, also raises the chance of complications in pregnancy, including the womb tears that medical staff see regularly.

Mohammed has remained in hospital in the two months since her C-section. Experiencing malnutrition, she got sick, while her son has been closely watched. The father has journeyed to other towns in search of work, so Mohammed is totally dependent on her mother.

The malnutrition ward has grown to six tents and has patients spilling over into other sections. Children lie under mosquito nets in oppressive temperatures in almost utter stillness as health workers work, mixing medications and measuring kids on a scale made from a pail and cord.

In moderate instances children get packets of PlumpyNut, the specially formulated peanut paste, but the critical situations need a regular intake of fortified formula. Mohammed’s baby is administered his nutrition through a injector.

Suhayba Abdullah Abubakar’s baby boy, Sufian Sulaiman, is being fed through a nasal drip. The infant has been unwell for the past year but Abubakar was repeatedly given only painkillers without any medical assessment, until she made the travel from Alacha to Metche.

“Every day, I see more children joining us in this structure,” she says. “The meals we consume is poor, there’s not enough to eat and it’s lacking in nutrients.

“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 reliant on what we’re distributed.”

And what they are given is a meager portion 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 acquires minimal items in the regular markets, where prices have become inflated.

Abubakar was moved to Alacha after coming from Sudan in 2023, having escaped the paramilitary 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 lives with his family members, dividing up whatever nourishment they obtain.

Abubakar says she has already witnessed 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 gravest emergency and the {scale of needs|extent