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For a long time, jolting along the flooded dirt track to the clinic, 18-year-old Makka Ibraheem Mohammed clung desperately to her seat and concentrated on stopping herself throwing up. She was in childbirth, in severe suffering after her womb tore, but was now being jostled relentlessly in the ambulance that jumped along the dips and bumps 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 inhospitable environment, are females. They live in remote settlements in the desert with insufficient supplies, no work and with medical help often a perilously remote away.

The clinic Mohammed needed was in Metche, one more encampment more than two hours away.

“I continuously experienced infections during my term and I had to go the health post seven times – when I was there, the pregnancy started. But I could not give birth normally because my uterine muscles failed,” says Mohammed. “I had to endure a long delay for the ambulance but all I remember was the agony; it was so intense I became delirious.”

Her mother, Ashe Khamis Abdullah, 40, feared she would suffer the death of her child and grandchild. But Mohammed was rushed straight into surgery when she got to the hospital and an emergency caesarean section rescued her and her son, Muwais.

Chad was known for the world’s second worst maternal fatality statistic before the recent arrival of refugees, but the situations faced by the Sudanese put even more women in risk.

At the hospital, where they have assisted in the arrival of 824 babies in often critical situations this year, the medics are able to save many, but it is what affects the women who are not able to reach the hospital that concerns them.

In the 24 months since the internal conflict in Sudan began, the vast majority of the displaced persons who came and stayed 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 previous conflict in Darfur.

Chad has hosted the bulk 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 almost twelve million Sudanese have been forced out of their homes.

Many males have stayed behind to be close to homes and land; others have been killed, captured or conscripted. Those of working age move on quickly from Chad’s isolated encampments to seek employment in the main city, N’Djamena, or elsewhere, in neighbouring Libya.

It implies women are abandoned, without the ability to sustain the young and old left in their responsibility. To reduce density near the border, the Chadian government has moved individuals to more compact settlements such as Metche with usual resident counts of about a large community, but in isolated regions with few facilities and few opportunities.

Metche has a hospital set up by a medical aid organization, which began as a few tents but has developed to contain an surgical room, but not much more. There is no work, families must travel long distances to find burning material, and each person must subsist with about minimal water of water a day – well under the suggested amount.

This isolation means hospitals are admitting women with complications 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 clinic near the camp at Alacha, where Mohammed is one of a large number of refugees. The medical team has observed instances where women in desperate pain have had to endure a full night for the ambulance to come.

Imagine being expecting a child, in labour, and travelling hours on a cart pulled by a donkey to get to a clinic

As well as being rough, the path goes through valleys that become inundated during the rainy season, completely blocking travel.

A surgeon at the hospital in Metche said each patient she treats is an critical situation, with some women having to make long and difficult journeys to the hospital by walking or on a mule.

“Imagine being in the late stages of pregnancy, in labour, and travelling hours on a donkey cart to get to a clinic. The primary issue is the wait but having to arrive under such circumstances also has an effect on the childbirth,” says the surgeon.

Malnutrition, which is increasing, also increases the risk of issues in pregnancy, including the womb tears that medical staff see regularly.

Mohammed has remained in hospital in the couple of months since her C-section. Afflicted by malnutrition, she got sick, while her son has been regularly checked. The male guardian has journeyed to other towns in seek jobs, so Mohammed is entirely leaning on her mother.

The nutritional care section has expanded to six tents and has cases exceeding capacity into other sections. Children are placed under mosquito nets in extreme warmth in almost utter stillness as health workers work, creating remedies and weighing children on a scale made from a container and string.

In less severe situations children get small bags of PlumpyNut, the specifically created peanut paste, but the critical situations need a consistent supply of nutrient-rich liquid. Mohammed’s baby is given his nourishment through a injector.

Suhayba Abdullah Abubakar’s baby boy, Sufian Sulaiman, is being nourished via a nose tube. The infant has been sick for the past year but Abubakar was consistently offered just painkillers without any identification, until she made the travel from Alacha to Metche.

“Every day, I see additional kids coming in in this tent,” she says. “The meals we consume is low-quality, there’s too little nourishment and it’s lacking in nutrients.

“If we were at home, we could’ve adapted ourselves. 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 allocated is a small amount of grain, cooking oil and salt, provided every couple of months. Such a basic diet is deficient in nutrients, and the little cash she is given acquires minimal items in the regular markets, where values have increased.

Abubakar was moved to Alacha after coming from Sudan in 2023, having fled the militia Rapid Support Forces’ attack on her home city of El Geneina in June that year.

Finding no work in Chad, her husband has gone to Libya in the hope of raising enough money for them to come later. She resides with his family members, dividing up whatever nourishment they obtain.

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