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For hours, bouncing over the waterlogged dirt track to the hospital, 18-year-old Makka Ibraheem Mohammed clung desperately to her seat and concentrated on stopping herself being sick. She was in childbirth, in extreme pain after her womb tore, but was now being shaken violently in the ambulance that lurched across 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 inhospitable environment, are females. They stay in remote settlements in the desert with scarce resources, no work and with healthcare often a perilously remote away.

The hospital Mohammed needed was in Metche, a different settlement more than a considerable journey away.

“I kept getting infections during my gestation and I had to go the health post seven times – when I was there, the pregnancy started. But I could not 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 can think of the agony; it was so bad I became delirious.”

Her mother, Ashe Khamis Abdullah, 40, worried she would lose both her child and grandchild. But Mohammed was hurried into surgery when she reached the hospital and an urgent C-section preserved the lives of her and her son, Muwais.

Chad already had the world’s second worst maternal fatality statistic before the recent arrival of refugees, but the conditions endured by the Sudanese expose further women in danger.

At the hospital, where they have delivered 824 babies in mostly emergency conditions this year, the doctors are able to save many, but it is what occurs with the women who are cannot access the hospital that concerns them.

In the two years since the domestic strife in Sudan started, the vast majority of the people who reached and remained in Chad are females and minors. In total, about one point two million Sudanese are being sheltered in the eastern part of the country, a large number 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; the remainder moved to South Sudan, Egypt and Ethiopia. A total of almost twelve million Sudanese have been uprooted from their homes.

Many males have remained to be in proximity to homes and land; many were murdered, captured or forced into fighting. Those of adult age move on quickly from Chad’s desolate refugee camps to look for jobs in the main city, N’Djamena, or elsewhere, in nearby Libya.

It means women are stranded, without the means to provide for the dependents left in their charge. To reduce density near the border, the Chadian government has moved individuals to more compact settlements such as Metche with average populations of about a large community, but in distant locations with no services and minimal chances.

Metche has a hospital set up by a medical aid organization, which started off as a few tents but has grown to feature an operating theatre, but not much more. There is a lack of jobs, families must journey for extended periods to find burning material, and each person must survive on about a small amount of water a day – well under the recommended 20 litres.

This remoteness means hospitals are admitting women with complications in their pregnancy when it is almost too late. There is only a sole emergency vehicle to serve the area between the Metche hospital and the clinic 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 wait an entire night for the ambulance to come.

Imagine being nine months pregnant, in delivery, and making a lengthy trip on a animal-drawn transport to get to a medical facility

As well as being rough, the route passes through valleys that become inundated during the wet period, completely preventing 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 foot or on a pack animal.

“Imagine being in the late stages of pregnancy, in childbirth, and travelling hours on a donkey cart to get to a hospital. The biggest factor is the wait but having to travel in this state also has an influence on the birth,” says the surgeon.

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

Mohammed has continued under care in the couple of months since her caesarean. Afflicted by malnutrition, she contracted an illness, while her son has been closely watched. The father has journeyed to other towns in look for employment, so Mohammed is totally dependent on her mother.

The malnutrition ward has expanded to six tents and has individuals overflowing into other sections. Children lie under mosquito nets in extreme warmth in almost total quiet as health workers work, mixing medications and measuring kids on a scale made from a container and string.

In less severe situations children get packets of PlumpyNut, the specially formulated peanut paste, but the worst cases need a daily dose of fortified formula. Mohammed’s baby is given his nourishment through a syringe.

Suhayba Abdullah Abubakar’s infant son, Sufian Sulaiman, is being fed through a nasogastric tube. The child has been sick for the past year but Abubakar was repeatedly given only painkillers without any medical assessment, until she made the journey from Alacha to Metche.

“Every day, I see additional kids coming in in this structure,” she says. “The nutrition we receive is low-quality, there’s too little nourishment and it’s not nutritious.

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

And what they are allocated is a meager portion of cereal, edible oil and salt, handed out every 60 days. Such a minimal nutrition lacks nutrition, and the little cash she is given cannot buy much in the local bazaars, where prices have become inflated.

Abubakar was moved to Alacha after coming from Sudan in 2023, having fled 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 desire to gathering adequate cash for them to join him. She lives with his family members, sharing out whatever meals they acquire.

Abubakar says she has already observed food supplies decreasing and there are fears that the abrupt cuts in overseas aid budgets by the US, UK and other European countries, could deteriorate conditions. Despite the war in Sudan having created the 21st century’s most severe crisis and the {scale of needs|extent