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For hours, bouncing over the soggy dirt track to the medical facility, 18-year-old Makka Ibraheem Mohammed clung desperately to her seat and concentrated on stopping herself throwing up. She was in delivery, in extreme pain after her womb tore, but was now being tossed around in the ambulance that jumped along 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, barely getting by in this difficult terrain, are females. They stay in secluded encampments in the desert with insufficient supplies, few job opportunities and with healthcare often a dangerously far away.

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

“I kept getting infections during my term and I had to go the health post on numerous visits – when I was there, the delivery commenced. But I found it impossible to give birth naturally because my uterine muscles failed,” says Mohammed. “I had to wait two hours for the ambulance but all I remember was the agony; it was so unbearable I became delirious.”

Her mother, Ashe Khamis Abdullah, 40, worried she would lose both her offspring and descendant. But Mohammed was immediately taken for 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 death rate before the recent arrival of refugees, but the conditions endured by the Sudanese put even more women in danger.

At the hospital, where they have birthed 824 babies in frequently urgent circumstances this year, the medical staff are able to rescue numerous, but it is what occurs with the women who are not able to reach the hospital that concerns them.

In the couple of years since the civil war in Sudan erupted, 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 hosted in the east of the country, 400,000 of whom ran from the previous conflict in Darfur.

Chad has taken the lion’s share of the millions of people who have run from the war in Sudan; others have gone to South Sudan, Egypt and Ethiopia. A total of millions of Sudanese have been forced out of their homes.

Many males have not left to be near homes and land; many were slain, captured or conscripted. Those of adult age rapidly leave from Chad’s isolated encampments to look for jobs in the main city, N’Djamena, or beyond, in adjacent Libya.

It implies women are left alone, without the resources to provide for the children and the elderly left in their charge. To prevent congestion near the border, the Chadian government has transferred refugees to smaller camps such as Metche with typical numbers of about fifty thousand, but in isolated regions with few facilities and minimal chances.

Metche has a hospital built by a medical aid organization, which started off as a few tents but has developed to contain an surgical room, but not much more. There is unemployment, families must journey for extended periods 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 seclusion means hospitals are treating women with issues in their pregnancy when it is almost too late. There is only a one medical transport to serve the area between the Metche hospital and the clinic 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 wait an entire night for the ambulance to reach them.

Imagine being in the final trimester, in labour, and travelling hours on a cart pulled by a donkey to get to a clinic

As well as being bumpy, the route passes through valleys that flood during the wet period, completely preventing 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 pack animal.

“Imagine being nine months pregnant, in labour, and making a long trip on a animal-drawn vehicle to get to a clinic. The biggest factor is the lag but having to travel in this state also has an effect on the birth,” says the surgeon.

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

Mohammed has remained in hospital in the couple of months since her caesarean. Suffering from malnutrition, she developed an infection, 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 malnutrition ward has grown to six tents and has patients spilling over into other sections. Children are placed under mosquito nets in extreme warmth in almost utter stillness as medical staff work, mixing medications and weighing children on a scale made from a pail and cord.

In mild cases children get sachets of PlumpyNut, the uniquely designed peanut paste, but the worst cases need a consistent supply of enriched milk. 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 further minors arriving in this tent,” she says. “The food we’re eating is poor, there’s not enough to eat and it’s lacking in nutrients.

“If we were at home, we could’ve adapted ourselves. You can go and grow crops, you can get a job, but here we’re relying on what we’re given.”

And what they are provided is a small amount of sorghum, edible oil and salt, handed out every couple of months. Such a minimal nutrition is deficient in nutrients, 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 run from the militia Rapid Support Forces’ assault on her home city of El Geneina in June that year.

Failing to secure jobs in Chad, her partner has left for Libya in the aspiration to gathering adequate cash for them to come later. She resides with his kin, dividing up whatever food they can get.

Abubakar says she has already witnessed food distributions being reduced and there are worries that the abrupt cuts 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 gravest emergency and the {scale of needs|extent