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For hours, travelling roughly on 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 childbirth, in severe suffering after her womb tore, but was now being shaken violently 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, surviving precariously in this harsh landscape, are women. They stay in isolated camps in the desert with limited water and food, few job opportunities and with treatment often a dangerously far away.

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

“I kept getting infections during my term and I had to go the health post on numerous visits – when I was there, the labour began. But I could not 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 suffering; it was so bad I became confused.”

Her parent, Ashe Khamis Abdullah, 40, worried she would suffer the death of her offspring and descendant. But Mohammed was hurried into surgery when she arrived at the hospital and an critical surgical delivery saved her and her son, Muwais.

Chad already had the world’s second most severe maternal fatality statistic before the ongoing stream of refugees, but the conditions endured by the Sudanese put even more women in danger.

At the hospital, where they have birthed 824 babies in often critical situations 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 civil war in Sudan began, 86% of the people who reached and settled in Chad are women and children. In total, about one point two million Sudanese are being accommodated 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 4.1 million people who have run from the war in Sudan; some have travelled to South Sudan, Egypt and Ethiopia. A total of millions of Sudanese have been uprooted from their homes.

Many males have stayed behind to be in proximity to homes and land; others have been killed, taken hostage or forced into fighting. Those of employable age rapidly leave from Chad’s barren settlements to find work in the capital, N’Djamena, or further, in adjacent Libya.

It results in women are abandoned, without the means to sustain the dependents left in their responsibility. To reduce density near the border, the Chadian government has transferred refugees to smaller camps such as Metche with average populations of about 50,000, but in distant locations with few facilities and few opportunities.

Metche has a hospital set up by a medical aid organization, which started off as a few tents but has expanded to include an surgical room, but not much more. There is a lack of jobs, families must travel long distances to find fuel, and each person must survive on about a small amount of water a day – far below the suggested amount.

This isolation means hospitals are receiving 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 health post near the Alacha encampment, where Mohammed is one of nearly 50,000 refugees. The medical team has encountered situations where women in extreme agony have had to wait an entire night for the ambulance to reach them.

Imagine being nine months pregnant, in delivery, and travelling hours on a cart pulled by a donkey to get to a clinic

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

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

“Imagine being about to give birth, in childbirth, and journeying for an extended time on a donkey cart to get to a hospital. The primary issue is the delay but having to come in these conditions also has an impact on the delivery,” says the surgeon.

Malnutrition, which is growing, also raises the chance of complications in pregnancy, including the uterine ruptures that medical staff frequently observe.

Mohammed has continued under care in the 60 days since her surgical delivery. Experiencing malnutrition, she contracted an illness, while her son has been closely watched. The father has gone to other towns in search of work, so Mohammed is entirely leaning on her mother.

The undernourishment unit has expanded to six tents and has cases exceeding capacity into other sections. Children lie under mosquito nets in extreme warmth in almost utter stillness as medical staff work, creating remedies and assessing weights on a instrument created using a bucket and rope.

In less severe situations children get packets of PlumpyNut, the specifically created peanut paste, but the critical situations need a consistent supply of nutrient-rich liquid. Mohammed’s baby is fed his through a medical device.

Suhayba Abdullah Abubakar’s infant son, Sufian Sulaiman, is being nourished via a nose tube. The baby has been ill for the past year but Abubakar was consistently offered just painkillers without any identification, until she made the travel from Alacha to Metche.

“Every day, I see more children coming in in this tent,” she says. “The meals we consume is low-quality, there’s insufficient food and it’s not nutritious.

“If we were at home, we could’ve adjusted our lives. You can go and grow crops, you can get a job, but here we’re relying on what we’re distributed.”

And what they are given is a meager portion of sorghum, cooking oil and salt, handed out every couple of months. Such a basic diet is deficient in nutrients, and the small amount of money she is given purchases very little in the local bazaars, where prices have become inflated.

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

Finding no work in Chad, her spouse has traveled to Libya in the hope of gathering adequate cash for them to join him. She stays with his kin, distributing whatever food they can get.

Abubakar says she has already seen food rations being cut and there are concerns that the sharp decreases in overseas aid budgets by the US, UK and other European countries, could make things worse. Despite the war in Sudan having created the 21st century’s gravest emergency and the {scale of needs|extent