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For hours, bouncing over the soggy dirt track to the hospital, 18-year-old Makka Ibraheem Mohammed held on tight to her seat and focused on stopping herself vomiting. 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 refugees who have fled to Chad since 2023, surviving precariously in this inhospitable environment, are females. They stay in remote settlements in the desert with limited water and food, little employment and with medical help often a dangerously far away.

The medical center Mohammed needed was in Metche, another refugee camp more than two hours away.

“I kept getting infections during my pregnancy and I had to go the medical tent seven times – when I was there, the delivery commenced. But I wasn’t able to give birth normally because my womb had given way,” says Mohammed. “I had to wait two hours for the ambulance but all I can think of the pain; it was so intense I became delirious.”

Her maternal figure, Ashe Khamis Abdullah, 40, was terrified she would be bereft of her offspring and descendant. But Mohammed was hurried into surgery when she arrived at the hospital and an critical surgical delivery preserved the lives of her and her son, Muwais.

Chad previously recorded the world’s second-highest maternal fatality statistic before the recent arrival of refugees, but the circumstances suffered by the Sudanese expose further women in peril.

At the hospital, where they have delivered 824 babies in mostly emergency conditions this year, the medical staff are able to save many, but it is what happens to the women who are fail to get to the hospital that alarms the professionals.

In the 24 months since the domestic strife in Sudan began, 86% of the people who reached and remained in Chad are women and children. In total, about 1.2 million Sudanese are being sheltered in the eastern region of the country, four hundred thousand of whom ran from the past violence in Darfur.

Chad has hosted the bulk of the over four million people who have fled the war in Sudan; others have gone to South Sudan, Egypt and Ethiopia. A total of millions of Sudanese have been displaced from their homes.

Many adult men have not left to be close to homes and land; others have been slain, taken hostage or forced into fighting. Those of adult age soon depart from Chad’s desolate refugee camps to seek employment in the capital, N’Djamena, or elsewhere, in neighbouring Libya.

It implies women are left alone, without the means to provide for the dependents left in their responsibility. To prevent congestion near the border, the Chadian government has moved individuals to more compact settlements such as Metche with average populations of about 50,000, but in remote areas with limited infrastructure and few opportunities.

Metche has a hospital built by a medical aid organization, which began as a few tents but has grown to feature an surgical room, but not much more. There is unemployment, families must journey for extended periods to find fuel, and each person must get by with about a small amount of water a day – well under the suggested amount.

This seclusion means hospitals are admitting women with problems in their pregnancy when it is almost too late. There is only a one medical transport to cover the route between the Metche hospital and the health post near the settlement of Alacha, where Mohammed is one of nearly 50,000 refugees. The medical team has encountered situations where women in desperate pain have had to remain overnight for the ambulance to reach them.

Imagine being nine months pregnant, in childbirth, and journeying for a long time on a donkey-drawn vehicle to get to a hospital

As well as being uneven, the route passes through valleys that become inundated during the wet period, completely cutting off travel.

A surgeon at the hospital in Metche said every case she sees is an crisis, with some women having to make long and difficult journeys to the hospital by on foot or on a donkey.

“Imagine being about to give birth, in delivery, and travelling hours on a donkey cart to get to a clinic. The biggest factor is the lag but having to arrive under such circumstances also has an effect on the birth,” says the surgeon.

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

Mohammed has stayed at the medical facility in the couple of months since her caesarean. Afflicted by malnutrition, she developed an infection, while her son has been closely watched. The father has gone to other towns in search of work, so Mohammed is totally dependent on her mother.

The nutritional care section has grown to six tents and has cases exceeding capacity into other sections. Children are placed under mosquito nets in sweltering heat in almost complete silence as health workers work, preparing treatments and assessing weights on a scale made from a container and string.

In mild cases children get small bags of PlumpyNut, the specially formulated peanut paste, but the critical situations need a consistent supply of nutrient-rich liquid. Mohammed’s baby is fed his through a syringe.

Suhayba Abdullah Abubakar’s infant son, Sufian Sulaiman, is being nourished via a nasal drip. The baby 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 joining us in this tent,” she says. “The food we’re eating is inadequate, there’s insufficient food and it’s lacking in nutrients.

“If we were at home, we could’ve adapted ourselves. You can go and cultivate plants, you can get a job, but here we’re relying on what we’re provided.”

And what they are given is a limited quantity of grain, cooking oil and salt, distributed every two months. Such a minimal nutrition lacks nutrition, and the little cash she is given acquires minimal items in the regular markets, where costs have risen.

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

Finding no work in Chad, her spouse has left for Libya in the hope of gathering adequate cash for them to come later. She stays with his family members, distributing whatever nourishment they obtain.

Abubakar says she has already witnessed food rations being cut and there are worries that the sharp decreases in overseas aid budgets by the US, UK and other European countries, could worsen the situation. Despite the war in Sudan having created the 21st century’s gravest emergency and the {scale of needs|extent