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For hours, bouncing over the waterlogged dirt track to the clinic, 18-year-old Makka Ibraheem Mohammed gripped firmly to her seat and focused on stopping herself throwing up. She was in childbirth, in agonizing discomfort after her uterine wall split, but was now being shaken violently in the ambulance that bumped over the potholes and ridges of the road through the Chadian desert.

Most of the hundreds of thousands of Sudanese refugees who have fled to Chad since 2023, barely getting by in this inhospitable environment, are females. They stay in remote settlements in the desert with limited water and food, little employment and with treatment often a dangerously far away.

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

“I kept getting infections during my gestation and I had to go the medical tent on numerous visits – when I was there, the labour began. But I found it impossible to give birth normally because my uterus had collapsed,” says Mohammed. “I had to endure a long delay 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 lose both her daughter and baby grandson. But Mohammed was immediately taken for surgery when she arrived at the hospital and an emergency caesarean section preserved the lives of her and her son, Muwais.

Chad already had the world’s second-highest maternal fatality statistic before the recent arrival of refugees, but the conditions endured by the Sudanese expose further women in peril.

At the hospital, where they have birthed 824 babies in often critical situations this year, the medics are able to rescue numerous, but it is what affects the women who are fail to get to the hospital that worries the staff.

In the 24 months since the internal conflict in Sudan started, 86% of the displaced persons who came and stayed in Chad are mothers and kids. In total, about 1.2 million Sudanese are being accommodated in the eastern region of the country, a large number of whom fled the previous conflict in Darfur.

Chad has taken the lion’s share of the 4.1 million people who have escaped the war in Sudan; the remainder moved to South Sudan, Egypt and Ethiopia. A total of millions of Sudanese have been uprooted from their homes.

Many adult men have remained to be close to homes and land; others have been killed, abducted or conscripted. Those of working age move on quickly from Chad’s barren settlements to look for jobs in the capital, N’Djamena, or elsewhere, in neighbouring Libya.

It means women are stranded, without the resources to provide for the children and the elderly left in their care. To reduce density near the border, the Chadian government has transferred refugees to more compact settlements such as Metche with typical numbers of about fifty thousand, but in remote areas with limited infrastructure and minimal chances.

Metche has a hospital set up by a medical aid organization, which began as a few tents but has grown to feature an procedure area, but little else. There is a lack of jobs, families must travel long distances to find fuel, and each person must get by with about a small amount of water a day – well under the suggested amount.

This isolation means hospitals are treating women with issues in their pregnancy when it is almost too late. There is only a one medical transport to serve the area between the Metche hospital and the health post near the camp at Alacha, where Mohammed is one of a large number of refugees. The medical team has seen cases where women in extreme agony have had to remain overnight for the ambulance to come.

Imagine being in the final trimester, in delivery, and travelling hours on a donkey-drawn vehicle to get to a hospital

As well as being bumpy, the road traverses 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 critical situation, with some women having to make arduous trips to the hospital by walking or on a mule.

“Imagine being in the late stages of pregnancy, in childbirth, and making a long trip on a animal-drawn vehicle to get to a medical center. The main problem is the wait but having to travel in this state also has an impact on the delivery,” says the surgeon.

Undernourishment, which is growing, also increases the risk of problems in pregnancy, including the womb tears that medical staff frequently observe.

Mohammed has stayed at the medical facility in the couple of months since her surgical delivery. Experiencing malnutrition, she got sick, while her son has been carefully monitored. The father has travelled to other towns in seek jobs, so Mohammed is completely reliant on her mother.

The nutritional care section has increased to six tents and has patients spilling over into other sections. Children are placed under mosquito nets in extreme warmth in almost complete silence as doctors and nurses work, preparing treatments and assessing weights on a scale made from a bucket and rope.

In mild cases children get packets of PlumpyNut, the specifically created peanut paste, but the worst cases need a daily dose of enriched milk. Mohammed’s baby is fed his through a medical device.

Suhayba Abdullah Abubakar’s baby boy, Sufian Sulaiman, is being nourished via a nose tube. The child has been ill for the past year but Abubakar was repeatedly given only painkillers without any identification, until she made the trip from Alacha to Metche.

“Every day, I see more children arriving in this shelter,” she says. “The food we’re eating is inadequate, there’s not enough to eat and it’s not nutritious.

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

And what they are allocated is a meager portion of cereal, cooking oil and salt, handed out every couple of months. Such a basic diet lacks nutrition, and the small amount of money she is given purchases very little in the regular markets, where prices have become inflated.

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

Unable to get employment in Chad, her partner has left for Libya in the hope of gathering adequate cash for them to join him. She stays with his kin, distributing whatever nourishment they obtain.

Abubakar says she has already witnessed food supplies decreasing and there are fears that the sharp decreases in overseas aid budgets 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