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For hours, jolting along the waterlogged dirt track to the hospital, 18-year-old Makka Ibraheem Mohammed held on tight to her seat and tried hard stopping herself throwing up. She was in labour, in extreme pain after her uterus ruptured, but was now being jostled relentlessly in the ambulance that bumped over the dips and bumps 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 inhospitable environment, are women. They reside in secluded encampments in the desert with scarce resources, few job opportunities and with treatment often a dangerously far away.

The medical center Mohammed needed was in Metche, one more encampment more than 120 minutes away.

“I continuously experienced infections during my term and I had to go the health post on numerous visits – when I was there, the pregnancy started. But I found it impossible to give birth without intervention 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 confused.”

Her maternal figure, Ashe Khamis Abdullah, 40, worried she would be bereft of her offspring and descendant. But Mohammed was rushed straight into surgery when she reached the hospital and an urgent C-section saved 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 put even more women in danger.

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 occurs with the women who are cannot access the hospital that concerns them.

In the two years since the civil war 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 east of the country, a large number of whom escaped the earlier war in Darfur.

Chad has accepted the majority of the over four million people who have escaped the war in Sudan; others have gone to South Sudan, Egypt and Ethiopia. A total of millions of Sudanese have been displaced from their homes.

Many adult men have remained to be in proximity to homes and land; some were slain, abducted or conscripted. Those of working age move on quickly from Chad’s isolated encampments to seek employment in the capital, N’Djamena, or elsewhere, in neighbouring Libya.

It means women are abandoned, without the ability to feed the young and old left in their care. To reduce density near the border, the Chadian government has moved individuals to smaller camps such as Metche with typical numbers of about fifty thousand, but in remote areas with limited infrastructure and few opportunities.

Metche has a hospital set up by a medical aid organization, which was initially a few tents but has expanded to include an procedure area, but little else. There is a lack of jobs, families must walk hours to find firewood, and each person must get by with about nine litres of water a day – much less than the suggested amount.

This seclusion means hospitals are treating 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 camp at Alacha, where Mohammed is one of a large number of refugees. The medical team has observed instances where women in extreme agony have had to remain overnight for the ambulance to arrive.

Imagine being expecting a child, in labour, and journeying for a long time on a donkey-drawn vehicle to get to a hospital

As well as being uneven, the route passes through valleys that become inundated during the wet period, completely blocking travel.

A surgeon at the hospital in Metche said all the situations she encounters is an emergency, with some women having to make arduous trips to the hospital by walking or on a mule.

“Imagine being about to give birth, in childbirth, and travelling hours on a cart pulled by a donkey to get to a medical center. The primary issue is the lag but having to arrive under such circumstances also has an effect on the birth,” says the surgeon.

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

Mohammed has stayed at the medical facility in the two months since her caesarean. Experiencing malnutrition, she contracted an illness, while her son has been closely watched. The parent has gone to other towns in search of work, so Mohammed is completely reliant on her mother.

The undernourishment unit has increased to six tents and has individuals overflowing into other sections. Children rest beneath mosquito nets in sweltering heat in almost total quiet as medical staff work, creating remedies and measuring kids on a instrument created using a bucket and rope.

In moderate instances children get packets of PlumpyNut, the uniquely designed peanut paste, but the critical situations need a regular intake of fortified formula. Mohammed’s baby is given his nourishment through a syringe.

Suhayba Abdullah Abubakar’s baby boy, Sufian Sulaiman, is being fed through a nose tube. The child has been ill for the past year but Abubakar was repeatedly given only painkillers without any diagnosis, until she made the travel from Alacha to Metche.

“Every day, I see additional kids joining us in this structure,” she says. “The food we’re eating is low-quality, there’s too little nourishment and it’s lacking in nutrients.

“If we were at home, we could’ve adjusted our lives. You can go and grow crops, you can find employment, but here we’re reliant on what we’re provided.”

And what they are provided is a meager portion of grain, vegetable oil and salt, distributed every two months. Such a basic diet offers little sustenance, and the meager funds she is given purchases very little in the regular markets, where costs have risen.

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

Failing to secure jobs in Chad, her husband has gone to Libya in the aspiration to raising enough money for them to join him. She resides with his relatives, distributing whatever nourishment they obtain.

Abubakar says she has already witnessed food distributions being reduced and there are worries that the sharp decreases in overseas aid budgets by the US, UK and other European countries, could worsen the situation. Despite the war in Sudan having caused the 21st century’s gravest emergency and the {scale of needs|extent