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For an extended period, jolting along the flooded dirt track to the hospital, 18-year-old Makka Ibraheem Mohammed gripped firmly to her seat and concentrated on stopping herself being sick. She was in labour, in severe suffering after her uterus ruptured, but was now being tossed around in the ambulance that bumped over the dips and bumps of the road through the Chadian desert.

Most of the close to a million Sudanese refugees who have fled to Chad since 2023, living hand to mouth in this difficult terrain, are women. They stay in secluded encampments in the desert with limited water and food, few job opportunities and with treatment often a life-threateningly long distance 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 medical tent multiple occasions – when I was there, the pregnancy started. But I wasn’t able to give birth naturally because my uterine muscles failed,” says Mohammed. “I had to wait two hours for the ambulance but all I recall is the pain; it was so bad I became disoriented.”

Her mother, Ashe Khamis Abdullah, 40, was terrified she would lose both her offspring and descendant. But Mohammed was hurried into surgery when she arrived at the hospital and an emergency caesarean section rescued her and her son, Muwais.

Chad was known for the world’s second worst 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 delivered 824 babies in often critical situations this year, the medics are able to rescue numerous, but it is what occurs with the women who are fail to get to the hospital that worries the staff.

In the couple of years since the internal conflict in Sudan erupted, over four-fifths of the displaced persons who came and stayed in Chad are mothers and kids. In total, about 1.2 million Sudanese are being accommodated in the eastern region of the country, four hundred thousand of whom fled the past violence in Darfur.

Chad has accepted the majority of the over four million people who have escaped the war in Sudan; the remainder moved to South Sudan, Egypt and Ethiopia. A total of millions of Sudanese have been forced out of their homes.

Many adult men have remained to be near homes and land; some were killed, taken hostage or conscripted. Those of adult age move on quickly from Chad’s desolate refugee camps to look for jobs in the capital, N’Djamena, or elsewhere, in adjacent Libya.

It means women are left alone, without the means to provide for the dependents left in their care. To reduce density near the border, the Chadian government has moved individuals to more compact settlements such as Metche with typical numbers of about fifty thousand, but in remote areas with no services and minimal chances.

Metche has a hospital established 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 walk hours to find burning material, and each person must get by with about minimal water of water a day – well under the recommended 20 litres.

This remoteness means hospitals are admitting women with complications in their pregnancy at a critical stage. 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 severe suffering have had to remain overnight for the ambulance to come.

Imagine being expecting a child, in delivery, and travelling hours on a cart pulled by a donkey to get to a hospital

As well as being rough, the path goes through valleys that become inundated during the wet period, completely cutting off travel.

A surgeon at the hospital in Metche said all the situations she encounters is an crisis, with some women having to make challenging travels to the hospital by walking or on a pack animal.

“Imagine being nine months pregnant, in delivery, and journeying for an extended time on a cart pulled by a donkey to get to a hospital. The primary issue is the lag but having to arrive under such circumstances also has an influence on the birth,” says the surgeon.

Undernourishment, which is on the rise, 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 couple of months since her caesarean. Suffering from malnutrition, she got sick, while her son has been carefully monitored. The father has gone to other towns in search of work, so Mohammed is totally dependent on her mother.

The malnutrition ward has grown to six tents and has individuals overflowing into other sections. Children are placed under mosquito nets in oppressive temperatures in almost complete silence as medical staff work, creating remedies and measuring kids on a scale made from a container and string.

In less severe situations children get sachets of PlumpyNut, the uniquely designed peanut paste, but the critical situations need a consistent supply of nutrient-rich liquid. Mohammed’s baby is given his nourishment through a injector.

Suhayba Abdullah Abubakar’s infant son, Sufian Sulaiman, is being nourished via a nasal drip. The child has been ill for the past year but Abubakar was repeatedly given only painkillers without any diagnosis, until she made the trip from Alacha to Metche.

“Every day, I see additional kids joining us in this tent,” she says. “The meals we consume is poor, there’s insufficient food and it’s deficient in vitamins.

“If we were at home, we could’ve coped better. You can go and cultivate plants, you can find employment, but here we’re dependent on what we’re distributed.”

And what they are allocated is a meager portion of grain, cooking oil and salt, provided every two months. Such a basic diet offers little sustenance, and the little cash she is given acquires minimal items in the local bazaars, where prices have become inflated.

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

Finding no work in Chad, her husband has left for Libya in the aspiration to gathering adequate cash for them to join him. She lives with his family members, sharing out whatever meals they acquire.

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