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For a long time, bouncing over the flooded 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 labour, in extreme pain after her uterine wall split, but was now being tossed around in the ambulance that lurched across the uneven terrain of the road through the Chadian desert.

Most of the hundreds of thousands of Sudanese displaced persons who escaped to Chad since 2023, living hand to mouth in this difficult terrain, are females. They reside in secluded encampments in the desert with limited water and food, little employment and with healthcare often a life-threateningly long distance away.

The hospital Mohammed needed was in Metche, a different settlement more than 120 minutes away.

“I kept getting infections during my term and I had to go the clinic multiple occasions – when I was there, the delivery commenced. But I wasn’t able to give birth without intervention because my womb had given way,” says Mohammed. “I had to endure a long delay for the ambulance but all I remember was the agony; it was so unbearable I became confused.”

Her maternal figure, Ashe Khamis Abdullah, 40, feared she would suffer the death of 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 was known for the world’s second worst maternal mortality rate before the current influx of refugees, but the situations faced by the Sudanese put even more women in risk.

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

In the two years since the internal conflict in Sudan started, 86% of the refugees who have arrived and remained in Chad are women and children. In total, about one point two million Sudanese are being accommodated in the eastern part of the country, four hundred thousand of whom fled the earlier war in Darfur.

Chad has taken the lion’s share of the over four million 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 forced out of their homes.

Many adult men have not left to be in proximity to homes and land; many were killed, taken hostage or conscripted. Those of employable age move on quickly from Chad’s barren settlements to look for jobs in the capital, N’Djamena, or beyond, in nearby Libya.

It implies women are left alone, without the means to sustain the dependents left in their care. To prevent congestion near the border, the Chadian government has transferred refugees to less crowded encampments such as Metche with average populations of about 50,000, but in remote areas with limited infrastructure and minimal chances.

Metche has a hospital set up by a medical aid organization, which started off as a few tents but has expanded to include an surgical room, but little else. There is no work, families must walk hours to find firewood, and each person must survive on about minimal water of water a day – well under the recommended 20 litres.

This isolation means hospitals are receiving women with problems in their pregnancy when it is almost too late. There is only a single ambulance to travel the path between the Metche hospital and the medical tent near the settlement of Alacha, where Mohammed is one of a large number of refugees. The medical team has encountered situations where women in severe suffering have had to endure a full night for the ambulance to reach them.

Imagine being expecting a child, in labour, and travelling hours on a animal-drawn transport to get to a clinic

As well as being rough, the route passes through valleys that flood during the rainy season, completely cutting off travel.

A surgeon at the hospital in Metche said all the situations she encounters is an critical situation, with some women having to make arduous trips to the hospital by foot or on a donkey.

“Imagine being in the late stages of pregnancy, in childbirth, and journeying for an extended time on a donkey cart to get to a hospital. The primary issue is the wait but having to travel in this state also has an influence on the delivery,” says the surgeon.

Malnutrition, which is on the rise, also raises the chance of complications in pregnancy, including the uterine ruptures that medical staff see regularly.

Mohammed has continued under care in the two months since her C-section. Experiencing malnutrition, she developed an infection, while her son has been closely watched. The male guardian has travelled to other towns in seek jobs, so Mohammed is totally dependent on her mother.

The undernourishment unit has grown 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, preparing treatments and weighing children on a device constructed from a bucket and rope.

In less severe situations children get sachets of PlumpyNut, the specially formulated peanut paste, but the worst cases need a consistent supply of nutrient-rich liquid. Mohammed’s baby is administered his nutrition through a injector.

Suhayba Abdullah Abubakar’s 11-month-old boy, Sufian Sulaiman, is being given nutrition by a nasogastric tube. The baby has been sick for the past year but Abubakar was repeatedly given only painkillers without any medical assessment, until she made the trip from Alacha to Metche.

“Every day, I see more children joining us in this shelter,” she says. “The food we’re eating is low-quality, there’s insufficient food and it’s not nutritious.

“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 small amount of sorghum, edible oil and salt, provided every two months. Such a minimal nutrition is deficient in nutrients, and the meager funds she is given purchases very little in the regular markets, where prices have become inflated.

Abubakar was relocated to Alacha after coming from Sudan in 2023, having fled the armed group Rapid Support Forces’ attack on her native town of El Geneina in June that year.

Failing to secure jobs in Chad, her husband has gone to Libya in the desire to gathering adequate cash for them to come later. She lives with his kin, distributing whatever food they can get.

Abubakar says she has already seen food supplies decreasing and there are concerns 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 most severe crisis and the {scale of needs|extent