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For a long time, travelling roughly on the flooded dirt track to the clinic, 18-year-old Makka Ibraheem Mohammed gripped firmly to her seat and focused on stopping herself being sick. She was in delivery, in extreme pain after her uterine wall split, but was now being shaken violently in the ambulance that jumped along the uneven terrain of the road through the Chadian desert.

Most of the 878,000 Sudanese people who ran to Chad since 2023, living hand to mouth in this difficult terrain, are women. They stay in remote settlements in the desert with scarce resources, few job opportunities and with treatment often a perilously remote away.

The hospital Mohammed needed was in Metche, a different settlement more than 120 minutes away.

“I repeatedly suffered from infections during my gestation and I had to go the medical tent multiple occasions – when I was there, the delivery commenced. 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 recall is the suffering; it was so unbearable I became delirious.”

Her parent, Ashe Khamis Abdullah, 40, worried she would lose both her offspring and descendant. But Mohammed was rushed straight into surgery when she got to the hospital and an critical surgical delivery saved her and her son, Muwais.

Chad already had the world’s second most severe maternal mortality rate before the current influx of refugees, but the situations faced by the Sudanese place additional women in risk.

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

In the two years since the internal conflict in Sudan erupted, over four-fifths of the people who reached and remained in Chad are women and children. In total, about one point two million Sudanese are being sheltered in the eastern part of the country, a large number of whom ran from the previous conflict in Darfur.

Chad has hosted the bulk of the over four 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 men have remained to be in proximity to homes and land; others have been murdered, captured or made to join the conflict. Those of employable age move on quickly from Chad’s barren settlements to look for jobs in the capital, N’Djamena, or elsewhere, in neighbouring Libya.

It implies women are abandoned, without the resources to sustain the children and the elderly left in their charge. To reduce density near the border, the Chadian government has moved individuals to smaller camps such as Metche with average populations of about fifty thousand, but in isolated regions with few facilities and few opportunities.

Metche has a hospital built by a medical aid organization, which was initially a few tents but has developed to contain an operating theatre, but little else. There is no work, families must journey for extended periods to find burning material, and each person must survive on about nine litres of water a day – well under the advised quantity.

This isolation means hospitals are admitting women with issues in their pregnancy dangerously late. There is only a sole emergency vehicle to travel the path between the Metche hospital and the medical tent near the Alacha encampment, where Mohammed is one of nearly 50,000 refugees. The medical team has observed instances where women in severe suffering have had to endure a full night for the ambulance to arrive.

Imagine being expecting a child, in labour, and making a lengthy trip on a donkey-drawn vehicle to get to a hospital

As well as being bumpy, the road traverses valleys that flood 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 arduous trips to the hospital by foot or on a pack animal.

“Imagine being nine months pregnant, in labour, and travelling hours on a animal-drawn vehicle to get to a hospital. The biggest factor is the wait but having to travel in this state also has an influence on the birth,” says the surgeon.

Undernourishment, which is growing, also elevates the likelihood of problems in pregnancy, including the uterine ruptures that medical staff frequently observe.

Mohammed has continued under care in the two months since her C-section. Afflicted by malnutrition, she got sick, while her son has been closely watched. The male guardian has journeyed to other towns in seek jobs, so Mohammed is totally dependent on her mother.

The nutritional care section has expanded to six tents and has individuals overflowing into other sections. Children lie 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 less severe situations children get small bags of PlumpyNut, the specially formulated peanut paste, but the most severe instances need a regular intake of enriched milk. Mohammed’s baby is fed his through a injector.

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

“Every day, I see further minors joining us in this tent,” she says. “The food we’re eating is inadequate, there’s insufficient food and it’s lacking in nutrients.

“If we were at home, we could’ve adapted ourselves. You can go and grow crops, you can find employment, but here we’re dependent on what we’re provided.”

And what they are given is a small amount of cereal, cooking oil and salt, provided every two months. Such a simple food offers little sustenance, and the little cash she is given purchases very little in the local bazaars, where costs have risen.

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

Unable to get employment in Chad, her spouse has gone to Libya in the aspiration to raising enough money for them to follow. She lives with his kin, distributing whatever meals they acquire.

Abubakar says she has already observed food distributions being reduced and there are concerns that the abrupt cuts 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 gravest emergency and the {scale of needs|extent