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For a long time, bouncing over the waterlogged dirt track to the medical facility, 18-year-old Makka Ibraheem Mohammed held on tight to her seat and focused on stopping herself being sick. She was in delivery, in agonizing discomfort after her uterus ruptured, but was now being tossed around in the ambulance that lurched across the uneven terrain of the road through the Chadian desert.

Most of the hundreds of thousands of Sudanese refugees who have fled to Chad since 2023, living hand to mouth in this difficult terrain, are females. They stay in secluded encampments in the desert with insufficient supplies, no work and with treatment often a dangerously far away.

The hospital Mohammed needed was in Metche, another refugee camp more than two hours away.

“I continuously experienced infections during my term and I had to go the clinic seven times – when I was there, the delivery commenced. But I found it impossible to give birth normally because my womb had given way,” says Mohammed. “I had to endure a long delay for the ambulance but all I remember was the agony; it was so unbearable I became disoriented.”

Her mother, Ashe Khamis Abdullah, 40, was terrified she would suffer the death of her daughter and baby grandson. But Mohammed was rushed straight into surgery when she got to the hospital and an emergency caesarean 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 conditions endured by the Sudanese expose further women in peril.

At the hospital, where they have birthed 824 babies in frequently urgent circumstances this year, the doctors are able to save many, but it is what affects the women who are cannot access the hospital that concerns them.

In the two years since the internal conflict in Sudan began, 86% of the displaced persons who came and remained in Chad are females and minors. In total, about over a million Sudanese are being sheltered in the eastern part of the country, a large number of whom fled the past violence in Darfur.

Chad has hosted the bulk of the over four million 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 forced out of their homes.

Many adult men have stayed behind to be in proximity to homes and land; many were murdered, abducted or forced into fighting. Those of employable age soon depart from Chad’s barren settlements to seek employment in the main city, N’Djamena, or beyond, in nearby Libya.

It results in women are left alone, without the means to provide for the dependents left in their charge. To avoid overcrowding 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 isolated regions with limited infrastructure and scarce prospects.

Metche has a hospital built by a medical aid organization, which began as a few tents but has developed to contain an procedure area, but few additional amenities. There is unemployment, families must travel long distances to find burning material, and each person must survive on about a small amount of water a day – far below the recommended 20 litres.

This seclusion means hospitals are treating 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 clinic near the Alacha encampment, where Mohammed is one of a large number of refugees. The medical team has encountered situations where women in desperate pain have had to endure a full night for the ambulance to arrive.

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

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

A surgeon at the hospital in Metche said every case she sees is an emergency, 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 animal-drawn vehicle to get to a hospital. The primary issue is the wait but having to travel in this state also has an impact on the birth,” says the surgeon.

Malnutrition, which is growing, also raises the chance of problems in pregnancy, including the uterine ruptures that medical staff frequently observe.

Mohammed has continued under care in the two months since her caesarean. Afflicted by malnutrition, she got sick, while her son has been regularly checked. The parent 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 are placed under mosquito nets in extreme warmth in almost total quiet as health workers work, mixing medications and measuring kids on a device constructed from a bucket and rope.

In moderate instances children get packets of PlumpyNut, the uniquely designed peanut paste, but the most severe instances need a consistent supply of nutrient-rich liquid. Mohammed’s baby is administered his nutrition through a medical device.

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

“Every day, I see more children arriving in this tent,” she says. “The nutrition we receive is poor, there’s insufficient food and it’s deficient in vitamins.

“If we were at home, we could’ve adjusted our lives. You can go and farm produce, you can get a job, but here we’re dependent on what we’re given.”

And what they are given is a small amount of grain, vegetable oil and salt, handed out every couple of months. Such a minimal nutrition lacks nutrition, and the meager funds she is given purchases very little in the regular markets, where values have increased.

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

Unable to get employment in Chad, her husband has traveled to Libya in the hope of gathering adequate cash for them to join him. She lives with his relatives, dividing up whatever nourishment they obtain.

Abubakar says she has already witnessed food distributions being reduced and there are worries that the sharp decreases in international assistance funds by the US, UK and other European countries, could make things worse. Despite the war in Sudan having produced the 21st century’s worst humanitarian disaster and the {scale of needs|extent