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For an extended period, jolting along the flooded dirt track to the clinic, 18-year-old Makka Ibraheem Mohammed gripped firmly to her seat and concentrated on stopping herself vomiting. She was in labour, in agonizing discomfort after her uterine wall split, but was now being tossed around in the ambulance that jumped along 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, living hand to mouth in this inhospitable environment, are women. They live in secluded encampments in the desert with scarce resources, no work and with healthcare often a life-threateningly long distance away.

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

“I continuously experienced infections during my gestation and I had to go the health post multiple occasions – when I was there, the delivery commenced. But I found it impossible to give birth normally because my uterine muscles failed,” says Mohammed. “I had to wait two hours for the ambulance but all I can think of the agony; it was so unbearable I became disoriented.”

Her parent, Ashe Khamis Abdullah, 40, was terrified she would lose both her child and grandchild. But Mohammed was hurried into surgery when she arrived at the hospital and an critical surgical delivery rescued her and her son, Muwais.

Chad was known for the world’s second most severe maternal mortality rate before the ongoing stream of refugees, but the conditions endured by the Sudanese place additional women in risk.

At the hospital, where they have assisted in the arrival of 824 babies in frequently urgent circumstances this year, the medical staff are able to rescue numerous, but it is what happens to the women who are cannot access the hospital that worries the staff.

In the two years since the civil war in Sudan erupted, over four-fifths of the refugees who have arrived and settled in Chad are women and children. In total, about over a million Sudanese are being hosted in the eastern region of the country, a large number of whom ran from the past violence in Darfur.

Chad has accepted the majority of the 4.1 million people who have fled the war in Sudan; some have travelled to South Sudan, Egypt and Ethiopia. A total of almost twelve million Sudanese have been forced out of their homes.

Many adult men have not left to be near homes and land; some were 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 main city, N’Djamena, or elsewhere, in adjacent Libya.

It implies women are abandoned, without the means to feed the dependents left in their care. To reduce density near the border, the Chadian government has relocated people to less crowded encampments such as Metche with typical numbers of about 50,000, but in remote areas with no services and scarce prospects.

Metche has a hospital established by a medical aid organization, which was initially 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 firewood, and each person must subsist with about a small amount of water a day – well under the recommended 20 litres.

This isolation means hospitals are admitting women with issues in their pregnancy at a critical stage. There is only a one medical transport to serve the area 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 extreme agony have had to remain overnight for the ambulance to reach them.

Imagine being in the final trimester, in childbirth, and travelling hours on a animal-drawn transport to get to a clinic

As well as being bumpy, the path goes through valleys that fill with water during the rainy season, completely blocking travel.

A surgeon at the hospital in Metche said each patient she treats is an critical situation, with some women having to make challenging travels to the hospital by walking or on a donkey.

“Imagine being nine months pregnant, in childbirth, and making a long trip on a cart pulled by a donkey to get to a clinic. The primary issue is the lag but having to travel in this state also has an effect on the childbirth,” says the surgeon.

Malnutrition, which is increasing, also increases the risk of complications in pregnancy, including the uterine ruptures that medical staff often encounter.

Mohammed has stayed at the medical facility in the couple of months since her caesarean. Afflicted by malnutrition, she got sick, while her son has been regularly checked. The father has journeyed to other towns in search of work, so Mohammed is entirely leaning on her mother.

The undernourishment unit has grown to six tents and has individuals overflowing into other sections. Children rest beneath mosquito nets in sweltering heat in almost total quiet as doctors and nurses work, preparing treatments and weighing children on a scale made from a bucket and rope.

In less severe situations children get sachets of PlumpyNut, the specifically created peanut paste, but the most severe instances need a regular intake of fortified formula. Mohammed’s baby is fed his through a syringe.

Suhayba Abdullah Abubakar’s 11-month-old boy, Sufian Sulaiman, is being nourished via a nose tube. The infant has been sick for the past year but Abubakar was only provided with painkillers without any identification, until she made the travel from Alacha to Metche.

“Every day, I see further minors arriving in this tent,” she says. “The meals we consume is inadequate, there’s insufficient food and it’s deficient in vitamins.

“If we were at home, we could’ve adapted ourselves. You can go and grow crops, you can work to earn some money, but here we’re relying on what we’re given.”

And what they are given is a small amount of sorghum, edible oil and salt, distributed every two months. Such a simple food lacks nutrition, and the meager funds she is given purchases very little in the local bazaars, where costs have risen.

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

Finding no work in Chad, her husband has gone to Libya in the aspiration to raising enough money for them to follow. She stays with his family members, distributing whatever meals they acquire.

Abubakar says she has already seen food supplies decreasing 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