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For a long time, 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 agonizing discomfort after her uterus ruptured, but was now being jostled relentlessly in the ambulance that lurched across the uneven terrain of the road through the Chadian desert.

Most of the close to a million Sudanese displaced persons who escaped to Chad since 2023, surviving precariously in this difficult terrain, are women. They reside in isolated camps in the desert with scarce resources, few job opportunities and with healthcare often a life-threateningly long distance away.

The clinic Mohammed needed was in Metche, another refugee camp more than two hours away.

“I continuously experienced infections during my term and I had to go the clinic on numerous visits – when I was there, the pregnancy started. But I wasn’t able to give birth normally because my uterus had collapsed,” says Mohammed. “I had to endure a long delay for the ambulance but all I recall is the agony; it was so unbearable I became confused.”

Her parent, Ashe Khamis Abdullah, 40, worried she would suffer the death of her child and grandchild. But Mohammed was immediately taken for surgery when she arrived at the hospital and an emergency caesarean section preserved the lives of her and her son, Muwais.

Chad already had the world’s second-highest maternal death rate before the ongoing stream of refugees, but the conditions endured by the Sudanese expose further women in risk.

At the hospital, where they have birthed 824 babies in mostly emergency conditions this year, the doctors are able to help plenty, but it is what affects the women who are not able to reach the hospital that worries the staff.

In the couple of years since the domestic strife in Sudan erupted, over four-fifths of the people who reached and remained in Chad are females and minors. In total, about one point two million Sudanese are being sheltered in the eastern part of the country, four hundred thousand of whom ran from the previous conflict in Darfur.

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

Many adult men have remained to be in proximity to homes and land; many were slain, captured or conscripted. Those of adult age soon depart from Chad’s isolated encampments to look for jobs in the main city, N’Djamena, or beyond, in neighbouring Libya.

It means women are left alone, without the means to feed the children and the elderly left in their charge. To avoid overcrowding near the border, the Chadian government has moved individuals to less crowded encampments such as Metche with average populations of about fifty thousand, but in distant locations with few facilities and few opportunities.

Metche has a hospital set up by a medical aid organization, which was initially a few tents but has developed to contain an operating theatre, but not much more. There is no work, families must travel long distances to find burning material, and each person must get by with about nine litres of water a day – well under the suggested amount.

This seclusion means hospitals are receiving women with issues in their pregnancy dangerously late. 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 close to fifty thousand refugees. The medical team has encountered situations where women in severe suffering have had to wait an entire night for the ambulance to come.

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

As well as being uneven, the route passes through valleys that flood during the monsoon, completely preventing travel.

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

“Imagine being nine months pregnant, in childbirth, and travelling hours on a animal-drawn vehicle to get to a clinic. The biggest factor is the wait but having to arrive under such circumstances also has an influence on the delivery,” says the surgeon.

Undernourishment, which is on the rise, also increases the risk of complications in pregnancy, including the womb tears that medical staff frequently observe.

Mohammed has continued under care in the couple of months since her caesarean. Suffering from malnutrition, she developed an infection, while her son has been regularly checked. The father has gone to other towns in seek jobs, so Mohammed is totally dependent on her mother.

The malnutrition ward has increased to six tents and has individuals overflowing into other sections. Children rest beneath mosquito nets in sweltering heat in almost complete silence as health workers work, creating remedies and weighing children on a scale made from a container and string.

In mild cases children get sachets of PlumpyNut, the specifically created peanut paste, but the most severe instances need a consistent supply of nutrient-rich liquid. Mohammed’s baby is fed his through a syringe.

Suhayba Abdullah Abubakar’s baby boy, Sufian Sulaiman, is being nourished via a nose tube. The infant has been sick for the past year but Abubakar was repeatedly given only painkillers without any diagnosis, until she made the journey from Alacha to Metche.

“Every day, I see additional kids coming in in this structure,” she says. “The nutrition we receive is poor, there’s insufficient food and it’s not nutritious.

“If we were at home, we could’ve adjusted our lives. You can go and farm produce, you can get a job, but here we’re reliant on what we’re given.”

And what they are provided is a small amount of sorghum, edible oil and salt, distributed every two months. Such a minimal nutrition lacks nutrition, and the small amount of money she is given cannot buy much in the local bazaars, where prices have become inflated.

Abubakar was transferred to Alacha after arriving from Sudan in 2023, having escaped the armed group Rapid Support Forces’ raid on her native town of El Geneina in June that year.

Finding no work in Chad, her partner has gone to Libya in the aspiration to gathering adequate cash for them to follow. She stays with his family members, sharing out whatever food they can get.

Abubakar says she has already seen food supplies decreasing and there are concerns that the sudden reductions in overseas aid budgets by the US, UK and other European countries, could deteriorate conditions. Despite the war in Sudan having produced the 21st century’s most severe crisis and the {scale of needs|extent