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For a long time, jolting along the flooded dirt track to the hospital, 18-year-old Makka Ibraheem Mohammed gripped firmly to her seat and tried hard stopping herself throwing up. She was in childbirth, in extreme pain after her uterus ruptured, but was now being jostled relentlessly in the ambulance that jumped along the potholes and ridges of the road through the Chadian desert.

Most of the close to a million Sudanese refugees who have fled to Chad since 2023, surviving precariously in this difficult terrain, are women. They stay in remote settlements in the desert with insufficient supplies, little employment and with treatment often a perilously remote away.

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

“I repeatedly suffered from infections during my pregnancy and I had to go the clinic multiple occasions – when I was there, the labour began. But I could not give birth naturally because my womb had given way,” says Mohammed. “I had to wait two hours for the ambulance but all I can think of the suffering; it was so intense I became disoriented.”

Her mother, Ashe Khamis Abdullah, 40, worried she would lose both her child and grandchild. But Mohammed was immediately taken for surgery when she got to the hospital and an emergency caesarean section preserved the lives of her and her son, Muwais.

Chad previously recorded the world’s second most severe maternal mortality rate before the recent arrival of refugees, but the situations faced by the Sudanese put even more women in peril.

At the hospital, where they have assisted in the arrival of 824 babies in frequently urgent circumstances this year, the medical staff are able to save many, but it is what happens to the women who are fail to get to the hospital that concerns them.

In the 24 months since the civil war in Sudan began, the vast majority of the displaced persons who came and remained in Chad are women and children. In total, about over a million Sudanese are being sheltered in the eastern part of the country, a large number of whom ran from the past violence in Darfur.

Chad has hosted the bulk of the over four million people who have fled the war in Sudan; the remainder moved to South Sudan, Egypt and Ethiopia. A total of 11.8 million Sudanese have been displaced from their homes.

Many men have remained to be near homes and land; many were murdered, taken hostage or conscripted. Those of employable age move on quickly from Chad’s desolate refugee camps to find work in the main city, N’Djamena, or elsewhere, in nearby Libya.

It results in women are abandoned, without the resources to provide for the children and the elderly left in their charge. To prevent congestion near the border, the Chadian government has transferred refugees to more compact settlements such as Metche with average populations of about 50,000, but in distant locations with limited infrastructure 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 not much more. There is unemployment, families must journey for extended periods to find fuel, and each person must subsist with about nine litres of water a day – far below the suggested amount.

This isolation means hospitals are receiving women with problems in their pregnancy dangerously late. There is only a single ambulance to serve the area 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 seen cases where women in desperate pain have had to remain overnight for the ambulance to come.

Imagine being nine months pregnant, in childbirth, and travelling hours on a donkey-drawn vehicle to get to a hospital

As well as being rough, the road traverses valleys that fill with water during the wet period, completely preventing travel.

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

“Imagine being in the late stages of pregnancy, in labour, and making a long trip on a donkey cart to get to a medical center. The primary issue is the delay but having to travel in this state also has an impact on the childbirth,” says the surgeon.

Malnutrition, which is increasing, also elevates the likelihood of complications in pregnancy, including the uterine splits that medical staff often encounter.

Mohammed has stayed at the medical facility in the 60 days since her C-section. Afflicted by malnutrition, she got sick, while her son has been regularly checked. The father has journeyed to other towns in search of work, so Mohammed is entirely leaning on her mother.

The malnutrition ward has grown to six tents and has cases exceeding capacity into other sections. Children lie under mosquito nets in sweltering heat in almost utter stillness as doctors and nurses work, creating remedies and weighing children on a instrument created using a container and string.

In mild cases children get sachets of PlumpyNut, the uniquely designed peanut paste, but the critical situations need a daily dose of enriched milk. Mohammed’s baby is given his nourishment through a injector.

Suhayba Abdullah Abubakar’s baby boy, Sufian Sulaiman, is being fed through a nasal drip. The infant has been sick 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 further minors joining us in this shelter,” she says. “The food we’re eating is low-quality, there’s not enough to eat and it’s lacking in nutrients.

“If we were at home, we could’ve coped better. You can go and farm produce, you can work to earn some money, but here we’re reliant on what we’re distributed.”

And what they are provided is a limited quantity of grain, vegetable oil and salt, handed out every 60 days. Such a basic diet lacks nutrition, and the meager funds she is given acquires minimal items in the regular markets, where values have increased.

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

Unable to get employment in Chad, her spouse has traveled to Libya in the desire to raising enough money for them to come later. She lives with his relatives, dividing up whatever nourishment they obtain.

Abubakar says she has already seen food rations being cut and there are concerns that the abrupt cuts in international assistance funds 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