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For a long time, travelling roughly on the flooded dirt track to the hospital, 18-year-old Makka Ibraheem Mohammed held on tight to her seat and focused on stopping herself throwing up. She was in childbirth, in extreme pain after her uterus ruptured, but was now being tossed around in the ambulance that lurched across the dips and bumps of the road through the Chadian desert.

Most of the close to a million Sudanese displaced persons who escaped to Chad since 2023, barely getting by in this inhospitable environment, are females. They reside in remote settlements in the desert with insufficient supplies, little employment and with treatment often a perilously remote away.

The medical center Mohammed needed was in Metche, one more encampment more than 120 minutes away.

“I repeatedly suffered from infections during my pregnancy and I had to go the clinic seven times – when I was there, the pregnancy started. But I could not give birth naturally because my womb had given way,” says Mohammed. “I had to remain for 120 minutes for the ambulance but all I can think of the pain; it was so unbearable I became confused.”

Her parent, Ashe Khamis Abdullah, 40, worried she would be bereft of her daughter and baby grandson. But Mohammed was immediately taken for surgery when she reached the hospital and an emergency caesarean section saved her and her son, Muwais.

Chad already had the world’s second-highest maternal death rate before the current influx of refugees, but the conditions endured by the Sudanese place additional women in danger.

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 occurs with the women who are cannot access the hospital that alarms the professionals.

In the two years since the civil war in Sudan started, 86% of the refugees who have arrived and remained in Chad are mothers and kids. In total, about over a million Sudanese are being sheltered in the eastern region of the country, four hundred thousand of whom fled the previous conflict in Darfur.

Chad has accepted the majority of the millions of people who have run from the war in Sudan; some have travelled to South Sudan, Egypt and Ethiopia. A total of 11.8 million Sudanese have been displaced from their homes.

Many adult men have not left to be in proximity to homes and land; some were murdered, abducted or forced into fighting. Those of working age rapidly leave from Chad’s barren settlements to look for jobs in the capital, N’Djamena, or beyond, in adjacent Libya.

It means women are left alone, without the ability to provide for the dependents left in their charge. To avoid overcrowding near the border, the Chadian government has relocated people to more compact settlements such as Metche with usual resident counts of about a large community, but in isolated regions with few facilities 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 surgical room, but not much more. There is unemployment, families must walk hours to find firewood, and each person must survive on about nine litres of water a day – far below the advised quantity.

This seclusion means hospitals are treating women with complications in their pregnancy at a critical stage. There is only a sole emergency vehicle to cover the route between the Metche hospital and the health post near the camp at Alacha, where Mohammed is one of nearly 50,000 refugees. The medical team has encountered situations where women in extreme agony have had to remain overnight for the ambulance to come.

Imagine being in the final trimester, in labour, and journeying for a long time on a donkey-drawn vehicle to get to a hospital

As well as being bumpy, the road traverses valleys that fill with water during the rainy season, completely blocking travel.

A surgeon at the hospital in Metche said every case she sees is an crisis, with some women having to make challenging travels to the hospital by walking or on a donkey.

“Imagine being nine months pregnant, in labour, and travelling hours on a cart pulled by a donkey to get to a medical center. The main problem is the delay but having to travel in this state also has an impact on the childbirth,” says the surgeon.

Malnutrition, which is increasing, also raises the chance of issues in pregnancy, including the uterine ruptures that medical staff frequently observe.

Mohammed has remained in hospital in the couple of months since her caesarean. Afflicted by malnutrition, she contracted an illness, while her son has been carefully monitored. The male guardian has gone to other towns in seek jobs, 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 are placed under mosquito nets in oppressive temperatures in almost complete silence as health workers work, preparing treatments and weighing children on a instrument created using a bucket and rope.

In mild cases children get packets of PlumpyNut, the uniquely designed peanut paste, but the most severe instances need a regular intake of nutrient-rich liquid. Mohammed’s baby is given his nourishment through a syringe.

Suhayba Abdullah Abubakar’s 11-month-old boy, Sufian Sulaiman, is being given nutrition by a nose tube. The child has been sick for the past year but Abubakar was consistently offered just painkillers without any medical assessment, until she made the travel from Alacha to Metche.

“Every day, I see additional kids coming in in this structure,” she says. “The food we’re eating is poor, there’s too little nourishment and it’s deficient in vitamins.

“If we were at home, we could’ve adapted ourselves. You can go and farm produce, you can get a job, but here we’re dependent on what we’re distributed.”

And what they are allocated is a meager portion of cereal, vegetable 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 weekly food markets, where prices have become inflated.

Abubakar was transferred to Alacha after coming from Sudan in 2023, having escaped the armed group Rapid Support Forces’ attack on her home city of El Geneina in June that year.

Finding no work in Chad, her partner has traveled to Libya in the hope of earning sufficient funds for them to come later. She lives with his relatives, sharing out whatever nourishment they obtain.

Abubakar says she has already witnessed food rations being cut and there are fears 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 most severe crisis and the {scale of needs|extent