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For an extended period, bouncing over the flooded dirt track to the hospital, 18-year-old Makka Ibraheem Mohammed clung desperately to her seat and concentrated on stopping herself being sick. She was in delivery, in extreme pain after her uterine wall split, but was now being tossed around in the ambulance that lurched across 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, barely getting by in this difficult terrain, are females. They live in isolated camps in the desert with limited water and food, little employment and with healthcare often a life-threateningly long distance away.

The hospital Mohammed needed was in Metche, another refugee camp more than 120 minutes away.

“I continuously experienced infections during my gestation and I had to go the clinic on numerous visits – when I was there, the delivery commenced. But I found it impossible to give birth naturally because my womb had given way,” 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 confused.”

Her maternal figure, Ashe Khamis Abdullah, 40, was terrified she would lose both her offspring and descendant. But Mohammed was hurried into surgery when she got to the hospital and an urgent C-section preserved the lives of her and her son, Muwais.

Chad was known for the world’s second worst maternal mortality rate before the ongoing stream of refugees, but the situations faced by the Sudanese expose further women in danger.

At the hospital, where they have delivered 824 babies in frequently urgent circumstances this year, the medics are able to save many, but it is what happens to the women who are not able to reach the hospital that alarms the professionals.

In the couple of years since the civil war in Sudan began, the vast majority of the refugees who have arrived and settled in Chad are females and minors. In total, about one point two million Sudanese are being accommodated in the eastern region of the country, 400,000 of whom fled the past violence in Darfur.

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

Many males have stayed behind to be in proximity to homes and land; others have been murdered, abducted or forced into fighting. Those of working age rapidly leave from Chad’s isolated encampments to look for jobs in the main city, N’Djamena, or beyond, in nearby Libya.

It results in women are left alone, without the ability to provide for the children and the elderly left in their care. To prevent congestion near the border, the Chadian government has relocated people to more compact settlements such as Metche with usual resident counts of about a large community, but in isolated regions with few facilities and minimal chances.

Metche has a hospital built by a medical aid organization, which began as a few tents but has expanded to include an surgical room, but few additional amenities. There is no work, families must journey for extended periods to find fuel, and each person must get by with about minimal water of water a day – much less than the suggested amount.

This remoteness means hospitals are treating women with problems in their pregnancy at a critical stage. There is only a sole emergency vehicle to cover the route between the Metche hospital and the medical tent near the settlement of Alacha, where Mohammed is one of nearly 50,000 refugees. The medical team has encountered situations where women in desperate pain have had to remain overnight for the ambulance to reach them.

Imagine being nine months pregnant, in childbirth, and making a lengthy trip on a cart pulled by a donkey to get to a hospital

As well as being uneven, the path goes through valleys that become inundated during the rainy season, completely cutting off travel.

A surgeon at the hospital in Metche said every case she sees is an crisis, with some women having to make challenging travels to the hospital by on foot or on a pack animal.

“Imagine being about to give birth, in labour, and travelling hours on a cart pulled by a donkey to get to a clinic. The primary issue is the delay but having to travel in this state also has an influence on the childbirth,” says the surgeon.

Poor nutrition, which is on the rise, also increases the risk of problems in pregnancy, including the uterine splits that medical staff frequently observe.

Mohammed has continued under care in the two months since her surgical delivery. Experiencing malnutrition, she developed an infection, while her son has been regularly checked. The father has journeyed to other towns in seek jobs, so Mohammed is totally dependent on her mother.

The nutritional care section has grown to six tents and has individuals overflowing into other sections. Children lie under mosquito nets in sweltering heat in almost total quiet as medical staff work, mixing medications and weighing children on a device constructed from a pail and cord.

In mild cases children get small bags of PlumpyNut, the specifically created peanut paste, but the worst cases need a consistent supply of fortified formula. Mohammed’s baby is given his nourishment through a medical device.

Suhayba Abdullah Abubakar’s infant son, Sufian Sulaiman, is being fed through a nose tube. The child has been ill for the past year but Abubakar was only provided with painkillers without any medical assessment, until she made the travel from Alacha to Metche.

“Every day, I see further minors 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 farm produce, you can find employment, but here we’re reliant on what we’re given.”

And what they are allocated is a limited quantity of cereal, cooking oil and salt, distributed every two months. Such a basic diet is deficient in nutrients, and the little cash she is given purchases very little in the local bazaars, where prices have become inflated.

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

Failing to secure jobs in Chad, her spouse has gone to Libya in the desire to raising enough money for them to come later. She lives with his family members, dividing up whatever meals they acquire.

Abubakar says she has already witnessed food distributions being reduced and there are worries that the sudden reductions 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 most severe crisis and the {scale of needs|extent