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For hours, jolting along the soggy dirt track to the medical facility, 18-year-old Makka Ibraheem Mohammed held on tight to her seat and focused on stopping herself being sick. She was in labour, in extreme pain after her uterus ruptured, but was now being shaken violently in the ambulance that lurched across the potholes and ridges 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 inhospitable environment, are females. They stay in isolated camps in the desert with insufficient supplies, few job opportunities and with treatment often a perilously remote away.

The hospital Mohammed needed was in Metche, a different settlement more than two hours away.

“I continuously experienced infections during my pregnancy and I had to go the medical tent seven times – when I was there, the pregnancy started. But I could not give birth normally because my uterus had collapsed,” says Mohammed. “I had to remain for 120 minutes for the ambulance but all I recall is the agony; it was so unbearable I became delirious.”

Her maternal figure, Ashe Khamis Abdullah, 40, feared she would be bereft of her child and grandchild. But Mohammed was hurried into surgery when she got to the hospital and an emergency caesarean section saved her and her son, Muwais.

Chad previously recorded the world’s second worst maternal mortality rate before the current influx of refugees, but the conditions endured by the Sudanese put even more women in danger.

At the hospital, where they have delivered 824 babies in mostly emergency conditions this year, the medical staff are able to rescue numerous, but it is what affects the women who are fail to get to the hospital that worries the staff.

In the couple of years since the civil war in Sudan began, over four-fifths of the people who reached and stayed in Chad are females and minors. In total, about one point two million Sudanese are being sheltered in the east of the country, four hundred thousand of whom ran from the past violence in Darfur.

Chad has taken the lion’s share of the over four million people who have run from 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 men have not left to be in proximity to homes and land; some were slain, captured or conscripted. Those of working age move on quickly from Chad’s barren settlements to find work in the main city, N’Djamena, or beyond, in neighbouring Libya.

It implies women are left alone, without the resources to feed the children and the elderly left in their care. To prevent congestion near the border, the Chadian government has moved individuals to less crowded encampments such as Metche with usual resident counts of about 50,000, but in distant locations with no services and minimal chances.

Metche has a hospital built by a medical aid organization, which began as a few tents but has grown to feature an procedure area, but little else. There is no work, families must walk hours to find firewood, and each person must subsist with about nine litres of water a day – much less than the suggested amount.

This remoteness means hospitals are admitting women with issues in their pregnancy when it is almost too late. There is only a single ambulance to cover the route between the Metche hospital and the health post near the camp at Alacha, where Mohammed is one of nearly 50,000 refugees. The medical team has encountered situations where women in severe suffering have had to endure a full night for the ambulance to reach them.

Imagine being nine months pregnant, in labour, and journeying for a long time on a donkey-drawn vehicle to get to a medical facility

As well as being rough, the route passes through valleys that flood during the monsoon, completely cutting off 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 about to give birth, in childbirth, and making a long trip on a cart pulled by a donkey to get to a hospital. The primary issue is the delay but having to travel in this state also has an impact on the birth,” says the surgeon.

Undernourishment, which is on the rise, also elevates the likelihood of problems in pregnancy, including the womb tears that medical staff frequently observe.

Mohammed has remained in hospital in the 60 days since her surgical delivery. Afflicted by malnutrition, she contracted an illness, while her son has been closely watched. The parent has journeyed to other towns in look for employment, so Mohammed is completely reliant on her mother.

The malnutrition ward has increased to six tents and has patients spilling over into other sections. Children rest beneath mosquito nets in oppressive temperatures in almost complete silence as health workers work, mixing medications and weighing children on a scale made from a bucket and rope.

In moderate instances children get small bags of PlumpyNut, the specifically created peanut paste, but the worst cases need a consistent supply of fortified formula. Mohammed’s baby is administered his nutrition through a syringe.

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

“Every day, I see more children coming in in this structure,” she says. “The nutrition we receive is low-quality, there’s insufficient food and it’s deficient in vitamins.

“If we were at home, we could’ve adapted ourselves. You can go and cultivate plants, you can work to earn some money, but here we’re reliant on what we’re provided.”

And what they are allocated is a small amount of sorghum, edible oil and salt, distributed every couple of months. Such a basic diet offers little sustenance, and the little cash she is given purchases very little in the weekly food markets, where values have increased.

Abubakar was moved to Alacha after coming from Sudan in 2023, having fled the paramilitary Rapid Support Forces’ raid on her home city of El Geneina in June that year.

Failing to secure jobs in Chad, her husband has gone to Libya in the desire to gathering adequate cash for them to follow. She resides with his relatives, distributing whatever meals they acquire.

Abubakar says she has already observed food rations being cut and there are worries that the sudden reductions in international assistance funds 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