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For a long time, travelling roughly on the waterlogged dirt track to the clinic, 18-year-old Makka Ibraheem Mohammed gripped firmly to her seat and tried hard stopping herself being sick. She was in delivery, in extreme pain after her uterine wall split, but was now being tossed around in the ambulance that lurched across 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, surviving precariously in this inhospitable environment, are women. They stay in secluded encampments in the desert with insufficient supplies, few job opportunities and with medical help often a dangerously far away.

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

“I repeatedly suffered from infections during my pregnancy and I had to go the medical tent multiple occasions – when I was there, the labour began. But I wasn’t able to give birth without intervention because my womb had given way,” says Mohammed. “I had to remain for 120 minutes for the ambulance but all I recall is the agony; it was so intense I became confused.”

Her mother, Ashe Khamis Abdullah, 40, was terrified 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 already had the world’s second worst maternal mortality rate before the ongoing stream of refugees, but the conditions endured by the Sudanese put even more women in risk.

At the hospital, where they have assisted in the arrival of 824 babies in often critical situations this year, the medical staff are able to save many, but it is what occurs with the women who are cannot access the hospital that alarms the professionals.

In the 24 months since the domestic strife in Sudan started, over four-fifths of the refugees who have arrived and remained in Chad are mothers and kids. In total, about one point two million Sudanese are being accommodated in the east of the country, a large number of whom ran from the past violence in Darfur.

Chad has hosted the bulk of the millions of people who have run from the war in Sudan; some have travelled to South Sudan, Egypt and Ethiopia. A total of almost twelve million Sudanese have been uprooted from their homes.

Many adult men have not left to be close to homes and land; some were murdered, captured or forced into fighting. Those of adult age move on quickly from Chad’s desolate refugee camps to look for jobs in the main city, N’Djamena, or elsewhere, in neighbouring Libya.

It results in women are stranded, without the ability to feed the children and the elderly left in their charge. To prevent congestion near the border, the Chadian government has transferred refugees to less crowded encampments such as Metche with usual resident counts of about fifty thousand, but in remote areas with no services and scarce prospects.

Metche has a hospital built by a medical aid organization, which started off as a few tents but has grown to feature an surgical room, but few additional amenities. There is a lack of jobs, families must walk hours to find burning material, and each person must survive on about nine litres of water a day – far below the recommended 20 litres.

This remoteness means hospitals are admitting women with issues in their pregnancy when it is almost too late. There is only a sole emergency vehicle to travel the path between the Metche hospital and the clinic near the settlement of Alacha, where Mohammed is one of nearly 50,000 refugees. The medical team has observed instances where women in severe suffering have had to wait an entire night for the ambulance to reach them.

Imagine being nine months pregnant, in childbirth, and making a lengthy trip on a donkey-drawn vehicle to get to a hospital

As well as being bumpy, the road traverses valleys that fill with water 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 on foot or on a pack animal.

“Imagine being nine months pregnant, in delivery, and travelling hours on a animal-drawn vehicle to get to a medical center. The biggest factor is the delay but having to travel in this state also has an influence on the delivery,” says the surgeon.

Undernourishment, which is growing, 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 two months since her caesarean. Afflicted by malnutrition, she got sick, while her son has been carefully monitored. The parent has travelled to other towns in seek jobs, so Mohammed is totally dependent on her mother.

The malnutrition ward has expanded to six tents and has individuals overflowing into other sections. Children rest beneath mosquito nets in oppressive temperatures in almost complete silence as medical staff work, creating remedies and assessing weights on a device constructed from a pail and cord.

In mild cases children get small bags of PlumpyNut, the uniquely designed peanut paste, but the worst cases need a regular intake of fortified formula. Mohammed’s baby is fed his through a injector.

Suhayba Abdullah Abubakar’s infant son, Sufian Sulaiman, is being nourished via a nasogastric tube. The infant has been ill for the past year but Abubakar was only provided with painkillers without any identification, until she made the journey from Alacha to Metche.

“Every day, I see more children arriving in this shelter,” she says. “The nutrition we receive is low-quality, there’s not enough to eat and it’s deficient in vitamins.

“If we were at home, we could’ve adjusted our lives. 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 provided is a meager portion of cereal, cooking oil and salt, distributed every two months. Such a basic diet lacks nutrition, and the little cash she is given cannot buy much in the weekly food markets, where prices have become inflated.

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

Unable to get employment in Chad, her partner has gone to Libya in the hope of raising enough money for them to come later. She resides with his kin, sharing out whatever meals they acquire.

Abubakar says she has already seen food supplies decreasing and there are fears 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 produced the 21st century’s worst humanitarian disaster and the {scale of needs|extent