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For a long time, bouncing over the soggy dirt track to the hospital, 18-year-old Makka Ibraheem Mohammed gripped firmly to her seat and concentrated on stopping herself throwing up. She was in delivery, in severe suffering after her uterus ruptured, but was now being jostled relentlessly in the ambulance that jumped along the uneven terrain of the road through the Chadian desert.

Most of the hundreds of thousands of Sudanese refugees who have fled to Chad since 2023, living hand to mouth in this difficult terrain, are women. They stay in isolated camps in the desert with limited water and food, little employment and with healthcare often a dangerously far away.

The clinic Mohammed needed was in Metche, a different settlement 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 delivery commenced. 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 suffering; it was so bad I became disoriented.”

Her parent, Ashe Khamis Abdullah, 40, feared she would suffer the death of her child and grandchild. But Mohammed was hurried into surgery when she reached the hospital and an critical surgical delivery saved her and her son, Muwais.

Chad already had the world’s second-highest maternal mortality rate before the recent arrival of refugees, but the conditions endured by the Sudanese place additional women in risk.

At the hospital, where they have birthed 824 babies in frequently urgent circumstances this year, the medics are able to save many, but it is what happens to the women who are cannot access the hospital that alarms the professionals.

In the two years since the domestic strife in Sudan erupted, over four-fifths of the refugees who have arrived and settled in Chad are females and minors. In total, about one point two million Sudanese are being hosted in the eastern region of the country, a large number of whom fled the earlier war in Darfur.

Chad has hosted the bulk of the over four million people who have escaped the war in Sudan; the remainder moved to South Sudan, Egypt and Ethiopia. A total of almost twelve million Sudanese have been forced out of their homes.

Many males have not left to be in proximity to homes and land; some were killed, captured or made to join the conflict. Those of working age rapidly leave from Chad’s barren settlements to seek employment in the capital, N’Djamena, or beyond, in adjacent Libya.

It means women are stranded, without the resources to feed the young and old left in their care. To avoid overcrowding near the border, the Chadian government has moved individuals to less crowded encampments such as Metche with typical numbers of about 50,000, but in distant locations with no services and few opportunities.

Metche has a hospital established by a medical aid organization, which began as a few tents but has expanded to include an operating theatre, but not much more. There is unemployment, families must journey for extended periods to find firewood, and each person must subsist with about a small amount of water a day – far below the suggested amount.

This seclusion means hospitals are receiving women with issues in their pregnancy dangerously late. There is only a single ambulance to serve the area between the Metche hospital and the medical tent near the camp at Alacha, where Mohammed is one of close to fifty thousand refugees. The medical team has seen cases where women in extreme agony have had to remain overnight for the ambulance to reach them.

Imagine being nine months pregnant, in labour, and travelling hours on a cart pulled by a donkey to get to a clinic

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 every case she sees is an emergency, 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 donkey cart to get to a hospital. The main problem is the delay but having to travel in this state also has an influence on the birth,” says the surgeon.

Poor nutrition, which is increasing, also increases the risk of issues in pregnancy, including the womb tears that medical staff frequently observe.

Mohammed has remained in hospital in the two months since her C-section. Experiencing malnutrition, she developed an infection, while her son has been regularly checked. The parent has travelled to other towns in search of work, so Mohammed is totally dependent 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 medical staff work, preparing treatments and measuring kids on a scale made from a container and string.

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

Suhayba Abdullah Abubakar’s baby boy, Sufian Sulaiman, is being fed through a nasal drip. The infant has been sick for the past year but Abubakar was only provided with painkillers without any medical assessment, until she made the travel from Alacha to Metche.

“Every day, I see more children coming in in this tent,” 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 grow crops, you can get a job, but here we’re relying on what we’re given.”

And what they are allocated is a limited quantity of sorghum, cooking oil and salt, distributed every couple of months. Such a basic diet is deficient in nutrients, and the small amount of money she is given purchases very little in the weekly food markets, where prices have become inflated.

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

Finding no work in Chad, her spouse has traveled to Libya in the desire to earning sufficient funds for them to join him. She resides with his family members, dividing up whatever nourishment they obtain.

Abubakar says she has already observed food distributions being reduced and there are fears that the abrupt cuts in foreign support money 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