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For hours, jolting along the soggy dirt track to the medical facility, 18-year-old Makka Ibraheem Mohammed gripped firmly to her seat and focused on stopping herself vomiting. She was in delivery, in extreme pain after her uterine wall split, but was now being shaken violently in the ambulance that jumped along the potholes and ridges of the road through the Chadian desert.

Most of the hundreds of thousands of Sudanese displaced persons who escaped to Chad since 2023, surviving precariously in this difficult terrain, are females. They live 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, one more encampment more than 120 minutes away.

“I kept getting infections during my term and I had to go the medical tent seven times – when I was there, the labour began. But I found it impossible to give birth normally because my uterine muscles failed,” says Mohammed. “I had to remain for 120 minutes for the ambulance but all I can think of the agony; it was so intense I became disoriented.”

Her parent, Ashe Khamis Abdullah, 40, was terrified she would suffer the death of her offspring and descendant. But Mohammed was immediately taken for surgery when she reached the hospital and an critical surgical delivery rescued her and her son, Muwais.

Chad already had the world’s second-highest maternal mortality rate before the ongoing stream of refugees, but the conditions endured by the Sudanese expose further women in risk.

At the hospital, where they have delivered 824 babies in often critical situations this year, the medics are able to help plenty, but it is what happens to the women who are fail to get to the hospital that worries the staff.

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 over a million Sudanese are being sheltered in the eastern region of the country, 400,000 of whom escaped the previous conflict in Darfur.

Chad has accepted the majority of the millions of people who have fled the war in Sudan; others have gone to South Sudan, Egypt and Ethiopia. A total of 11.8 million Sudanese have been uprooted from their homes.

Many males have stayed behind to be near homes and land; some were murdered, taken hostage or forced into fighting. Those of employable age move on quickly from Chad’s isolated encampments to look for jobs in the main city, N’Djamena, or elsewhere, in neighbouring Libya.

It means women are abandoned, without the means to provide for the young and old left in their care. To reduce density near the border, the Chadian government has transferred refugees to smaller camps such as Metche with usual resident counts of about fifty thousand, but in remote areas with limited infrastructure and few opportunities.

Metche has a hospital set up by a medical aid organization, which was initially a few tents but has developed to contain an operating theatre, but little else. There is unemployment, families must travel long distances to find firewood, and each person must survive on about nine litres of water a day – well under the suggested amount.

This isolation means hospitals are receiving women with issues in their pregnancy dangerously late. There is only a one medical transport to travel the path between the Metche hospital and the medical tent near the camp at Alacha, where Mohammed is one of nearly 50,000 refugees. The medical team has observed instances where women in severe suffering have had to wait an entire night for the ambulance to reach them.

Imagine being nine months pregnant, in childbirth, and travelling hours on a donkey-drawn vehicle to get to a hospital

As well as being rough, the path goes through valleys that fill with water during the rainy season, 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 arduous trips to the hospital by on foot or on a donkey.

“Imagine being nine months pregnant, in labour, and journeying for an extended time on a animal-drawn vehicle to get to a clinic. The biggest factor is the wait but having to arrive under such circumstances also has an impact on the birth,” says the surgeon.

Undernourishment, which is growing, also raises the chance of complications in pregnancy, including the uterine splits that medical staff frequently observe.

Mohammed has stayed at the medical facility in the 60 days since her C-section. Suffering from malnutrition, she contracted an illness, while her son has been closely watched. The father has gone to other towns in look for employment, so Mohammed is totally dependent on her mother.

The undernourishment unit has expanded to six tents and has individuals overflowing into other sections. Children rest beneath mosquito nets in oppressive temperatures in almost complete silence as health workers work, creating remedies and measuring kids on a device constructed from a container and string.

In less severe situations children get sachets of PlumpyNut, the specially formulated peanut paste, but the critical situations need a daily dose of enriched milk. Mohammed’s baby is given his nourishment through a injector.

Suhayba Abdullah Abubakar’s 11-month-old boy, Sufian Sulaiman, is being given nutrition by a nasogastric tube. The child has been ill 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 additional kids coming in in this shelter,” she says. “The meals we consume is low-quality, there’s insufficient food and it’s lacking in nutrients.

“If we were at home, we could’ve adjusted our lives. You can go and grow crops, you can find employment, but here we’re relying on what we’re provided.”

And what they are allocated is a limited quantity of grain, edible oil and salt, provided every two months. Such a minimal nutrition offers little sustenance, and the small amount of money she is given acquires minimal items in the regular markets, where costs have risen.

Abubakar was transferred to Alacha after reaching from Sudan in 2023, having fled the paramilitary Rapid Support Forces’ raid on her native town 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 follow. She stays with his family members, distributing whatever nourishment they obtain.

Abubakar says she has already observed food distributions being reduced and there are worries that the sudden reductions in foreign support money by the US, UK and other European countries, could make things worse. Despite the war in Sudan having caused the 21st century’s worst humanitarian disaster and the {scale of needs|extent