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For hours, jolting along the flooded dirt track to the hospital, 18-year-old Makka Ibraheem Mohammed gripped firmly to her seat and focused on stopping herself throwing up. She was in childbirth, in severe suffering after her womb tore, but was now being shaken violently in the ambulance that jumped along 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, surviving precariously in this difficult terrain, are females. They reside in remote settlements in the desert with scarce resources, no work and with healthcare often a life-threateningly long distance away.

The hospital Mohammed needed was in Metche, another refugee camp more than a considerable journey away.

“I repeatedly suffered from infections during my term 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 endure a long delay for the ambulance but all I remember was the agony; it was so unbearable I became disoriented.”

Her maternal figure, Ashe Khamis Abdullah, 40, was terrified she would lose both her daughter and baby grandson. But Mohammed was immediately taken for surgery when she reached the hospital and an urgent C-section saved her and her son, Muwais.

Chad previously recorded the world’s second most severe maternal fatality statistic before the ongoing stream of refugees, but the circumstances suffered by the Sudanese place additional women in peril.

At the hospital, where they have birthed 824 babies in frequently urgent circumstances this year, the medics are able to save many, but it is what occurs with the women who are not able to reach the hospital that worries the staff.

In the 24 months since the domestic strife in Sudan started, 86% of the refugees who have arrived and stayed in Chad are women and children. In total, about over a million Sudanese are being hosted in the eastern region of the country, four hundred thousand of whom fled the previous conflict in Darfur.

Chad has taken the lion’s share of the millions of people who have fled the war in Sudan; some have travelled to South Sudan, Egypt and Ethiopia. A total of 11.8 million Sudanese have been uprooted from their homes.

Many males have not left to be near homes and land; many were murdered, abducted or conscripted. Those of employable age move on quickly from Chad’s desolate refugee camps to find work in the capital, N’Djamena, or further, in adjacent Libya.

It results in women are abandoned, without the resources to provide for the dependents left in their responsibility. To avoid overcrowding near the border, the Chadian government has transferred refugees to less crowded encampments such as Metche with average populations of about a large community, but in distant locations with limited infrastructure and scarce prospects.

Metche has a hospital built by a medical aid organization, which began as a few tents but has grown to feature an operating theatre, but little else. There is no work, families must walk hours to find burning material, 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 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 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 reach them.

Imagine being in the final trimester, in labour, and travelling hours on a cart pulled by a donkey to get to a hospital

As well as being rough, the road traverses valleys that become inundated during the rainy season, completely preventing travel.

A surgeon at the hospital in Metche said all the situations she encounters is an emergency, with some women having to make long and difficult journeys to the hospital by on foot or on a pack animal.

“Imagine being nine months pregnant, in childbirth, and journeying for an extended time on a animal-drawn vehicle to get to a medical center. The biggest factor is the wait but having to come in these conditions also has an effect on the delivery,” says the surgeon.

Undernourishment, which is increasing, also increases the risk of complications in pregnancy, including the uterine ruptures that medical staff frequently observe.

Mohammed has continued under care in the 60 days since her C-section. Suffering from malnutrition, she developed an infection, while her son has been regularly checked. The father has journeyed 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 rest beneath mosquito nets in extreme warmth in almost utter stillness as doctors and nurses work, preparing treatments and measuring kids on a scale made from a bucket and rope.

In less severe situations children get packets of PlumpyNut, the specifically created peanut paste, but the most severe instances need a regular intake of fortified formula. Mohammed’s baby is administered his nutrition through a injector.

Suhayba Abdullah Abubakar’s baby boy, Sufian Sulaiman, is being given nutrition by a nose tube. The baby has been sick for the past year but Abubakar was only provided with painkillers without any medical assessment, until she made the journey from Alacha to Metche.

“Every day, I see more children coming in in this structure,” she says. “The nutrition we receive is low-quality, there’s not enough to eat and it’s deficient in vitamins.

“If we were at home, we could’ve coped better. 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 provided is a limited quantity of cereal, cooking oil and salt, distributed 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 costs have risen.

Abubakar was transferred to Alacha after coming from Sudan in 2023, having run from the militia Rapid Support Forces’ raid on her birthplace of El Geneina in June that year.

Finding no work in Chad, her partner has gone to Libya in the hope of earning sufficient funds for them to join him. She lives with his family members, sharing out whatever meals they acquire.

Abubakar says she has already witnessed food rations being cut and there are concerns that the sudden reductions in overseas aid budgets by the US, UK and other European countries, could make things worse. Despite the war in Sudan having caused the 21st century’s most severe crisis and the {scale of needs|extent