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For an extended period, travelling roughly on the waterlogged dirt track to the medical facility, 18-year-old Makka Ibraheem Mohammed clung desperately to her seat and tried hard stopping herself being sick. She was in childbirth, in severe suffering after her womb tore, but was now being jostled relentlessly in the ambulance that jumped along the potholes and ridges of the road through the Chadian desert.

Most of the hundreds of thousands of Sudanese refugees who have fled to Chad since 2023, barely getting by in this inhospitable environment, are females. They reside in isolated camps in the desert with limited water and food, no work and with treatment often a perilously remote away.

The medical center Mohammed needed was in Metche, one more encampment more than 120 minutes away.

“I continuously experienced infections during my gestation and I had to go the medical tent seven times – when I was there, the pregnancy started. But I wasn’t able to give birth normally because my uterine muscles failed,” says Mohammed. “I had to endure a long delay for the ambulance but all I recall is the pain; it was so intense I became delirious.”

Her parent, Ashe Khamis Abdullah, 40, worried she would be bereft of her daughter and baby grandson. But Mohammed was immediately taken for surgery when she arrived at the hospital and an critical surgical delivery saved her and her son, Muwais.

Chad previously recorded the world’s second most severe maternal death rate before the recent arrival of refugees, but the situations faced by the Sudanese put even more women in danger.

At the hospital, where they have delivered 824 babies in frequently urgent circumstances this year, the medical staff are able to save many, but it is what occurs with the women who are not able to reach the hospital that worries the staff.

In the two years since the internal conflict in Sudan began, over four-fifths of the people who reached and remained in Chad are mothers and kids. In total, about over a million Sudanese are being sheltered in the eastern part of the country, four hundred thousand of whom escaped the past violence in Darfur.

Chad has hosted the bulk of the over four million people who have fled the war in Sudan; some have travelled to South Sudan, Egypt and Ethiopia. A total of 11.8 million Sudanese have been displaced from their homes.

Many males have stayed behind to be close to homes and land; others have been killed, captured or made to join the conflict. Those of working age move on quickly from Chad’s isolated encampments to seek employment in the capital, N’Djamena, or elsewhere, in nearby Libya.

It implies women are stranded, without the means to provide for the young and old left in their care. To reduce density near the border, the Chadian government has relocated people to smaller camps such as Metche with typical numbers of about a large community, but in distant locations with limited infrastructure and scarce prospects.

Metche has a hospital established by a medical aid organization, which started off as a few tents but has grown to feature an surgical room, but little else. There is a lack of jobs, families must travel long distances to find burning material, and each person must subsist with about a small amount of water a day – well under the recommended 20 litres.

This remoteness means hospitals are treating women with problems in their pregnancy dangerously late. There is only a one medical transport 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 observed instances where women in desperate pain have had to remain overnight 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 rough, the road traverses valleys that flood during the rainy season, completely blocking travel.

A surgeon at the hospital in Metche said all the situations she encounters is an emergency, with some women having to make long and difficult journeys to the hospital by on foot or on a pack animal.

“Imagine being about to give birth, in delivery, and travelling hours on a animal-drawn vehicle to get to a hospital. The primary issue is the wait but having to travel in this state also has an impact on the birth,” says the surgeon.

Undernourishment, which is growing, 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 got sick, while her son has been regularly checked. The parent has gone to other towns in seek jobs, so Mohammed is entirely leaning on her mother.

The undernourishment unit has increased to six tents and has cases exceeding capacity into other sections. Children are placed under mosquito nets in extreme warmth in almost total quiet as medical staff work, creating remedies and assessing weights on a device constructed from a bucket and rope.

In less severe situations children get packets of PlumpyNut, the specifically created peanut paste, but the most severe instances need a daily dose of nutrient-rich liquid. Mohammed’s baby is given his nourishment through a injector.

Suhayba Abdullah Abubakar’s 11-month-old boy, Sufian Sulaiman, is being nourished via a nasogastric tube. The infant has been sick for the past year but Abubakar was consistently offered just painkillers without any medical assessment, until she made the journey from Alacha to Metche.

“Every day, I see additional kids joining us in this tent,” she says. “The food we’re eating is inadequate, there’s insufficient food and it’s lacking in nutrients.

“If we were at home, we could’ve coped better. You can go and farm produce, you can work to earn some money, but here we’re relying on what we’re distributed.”

And what they are given is a meager portion of cereal, edible oil and salt, distributed every couple of months. Such a minimal nutrition offers little sustenance, and the little cash she is given purchases very little in the weekly food markets, where prices have become inflated.

Abubakar was transferred to Alacha after arriving from Sudan in 2023, having fled the paramilitary 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 desire to earning sufficient funds for them to come later. She stays with his family members, sharing out whatever food they can get.

Abubakar says she has already seen food distributions being reduced and there are fears that the sharp decreases in international assistance funds by the US, UK and other European countries, could worsen the situation. Despite the war in Sudan having produced the 21st century’s most severe crisis and the {scale of needs|extent