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For an extended period, jolting along the waterlogged dirt track to the hospital, 18-year-old Makka Ibraheem Mohammed clung desperately to her seat and tried hard stopping herself being sick. She was in delivery, in extreme pain after her womb tore, but was now being jostled relentlessly 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, living hand to mouth in this difficult terrain, are women. They reside in isolated camps in the desert with scarce resources, no work and with medical help often a life-threateningly long distance away.

The hospital Mohammed needed was in Metche, a different settlement more than two hours away.

“I kept getting infections during my term and I had to go the health post multiple occasions – when I was there, the labour began. But I could not give birth normally because my uterus had collapsed,” says Mohammed. “I had to wait two hours for the ambulance but all I recall is the agony; it was so unbearable I became disoriented.”

Her maternal figure, Ashe Khamis Abdullah, 40, worried she would lose both her daughter and baby grandson. But Mohammed was immediately taken for surgery when she reached the hospital and an critical surgical delivery saved her and her son, Muwais.

Chad previously recorded the world’s second worst maternal death rate before the recent arrival of refugees, but the circumstances suffered by the Sudanese place additional women in peril.

At the hospital, where they have delivered 824 babies in mostly emergency conditions this year, the medics are able to rescue numerous, but it is what happens to the women who are fail to get to the hospital that alarms the professionals.

In the couple of years since the internal conflict in Sudan erupted, over four-fifths of the displaced persons who came and remained in Chad are females and minors. In total, about 1.2 million Sudanese are being sheltered in the east of the country, 400,000 of whom ran from the earlier war in Darfur.

Chad has taken the lion’s share 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 millions of Sudanese have been uprooted from their homes.

Many adult men have not left to be near homes and land; many were killed, taken hostage or made to join the conflict. Those of employable age move on quickly from Chad’s barren settlements to find work in the main city, N’Djamena, or further, in neighbouring Libya.

It implies women are stranded, without the ability to provide for the children and the elderly left in their care. To avoid overcrowding near the border, the Chadian government has relocated people to smaller camps such as Metche with typical numbers of about 50,000, but in isolated regions with few facilities and few opportunities.

Metche has a hospital built by a medical aid organization, which began as a few tents but has developed to contain an surgical room, but little else. There is no work, families must travel long distances to find fuel, and each person must get by with about nine litres of water a day – far below the recommended 20 litres.

This remoteness means hospitals are treating women with complications in their pregnancy when it is almost too late. There is only a single ambulance to cover the route 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 seen cases where women in extreme agony have had to endure a full night for the ambulance to come.

Imagine being expecting a child, in labour, and journeying for a long time on a cart pulled by a donkey to get to a hospital

As well as being bumpy, the road traverses valleys that flood 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 about to give birth, in delivery, and making a long trip on a donkey cart to get to a medical center. The primary issue is the delay but having to arrive under such circumstances also has an influence on the birth,” says the surgeon.

Undernourishment, which is increasing, also increases the risk of complications in pregnancy, including the womb tears that medical staff often encounter.

Mohammed has stayed at the medical facility in the couple of months since her caesarean. Afflicted by malnutrition, she developed an infection, while her son has been closely watched. The male guardian has gone to other towns in look for employment, so Mohammed is completely reliant on her mother.

The malnutrition ward has expanded to six tents and has cases exceeding capacity into other sections. Children lie under mosquito nets in extreme warmth in almost complete silence as health workers work, creating remedies and measuring kids on a device constructed from a pail and cord.

In mild cases children get sachets of PlumpyNut, the specially formulated peanut paste, but the worst cases need a daily dose of fortified formula. Mohammed’s baby is fed his through a syringe.

Suhayba Abdullah Abubakar’s infant son, Sufian Sulaiman, is being given nutrition by a nasal drip. The baby has been sick for the past year but Abubakar was consistently offered just painkillers without any identification, until she made the journey from Alacha to Metche.

“Every day, I see more children coming in in this tent,” she says. “The nutrition we receive is low-quality, there’s insufficient food and it’s lacking in nutrients.

“If we were at home, we could’ve adjusted our lives. You can go and cultivate plants, you can work to earn some money, but here we’re reliant on what we’re provided.”

And what they are provided is a limited quantity of grain, edible oil and salt, handed out every two months. Such a simple food is deficient in nutrients, and the meager funds she is given cannot buy much in the local bazaars, where costs have risen.

Abubakar was transferred to Alacha after reaching from Sudan in 2023, having fled the militia Rapid Support Forces’ assault on her home city 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 come later. She lives with his kin, dividing up whatever nourishment they obtain.

Abubakar says she has already seen food rations being cut and there are worries that the sharp decreases in international assistance funds by the US, UK and other European countries, could deteriorate conditions. Despite the war in Sudan having created the 21st century’s worst humanitarian disaster and the {scale of needs|extent