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For an extended period, jolting along the soggy dirt track to the hospital, 18-year-old Makka Ibraheem Mohammed held on tight to her seat and tried hard stopping herself throwing up. She was in labour, in agonizing discomfort after her womb tore, but was now being jostled relentlessly in the ambulance that jumped along the uneven terrain of the road through the Chadian desert.

Most of the close to a million Sudanese refugees who have fled to Chad since 2023, living hand to mouth in this harsh landscape, are females. They live 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, a different settlement more than two hours away.

“I kept getting infections during my term and I had to go the medical tent multiple occasions – when I was there, the delivery commenced. But I found it impossible to give birth without intervention because my uterus had collapsed,” says Mohammed. “I had to wait two hours for the ambulance but all I recall is the agony; it was so intense I became delirious.”

Her maternal figure, Ashe Khamis Abdullah, 40, was terrified she would suffer the death of her daughter and baby grandson. But Mohammed was hurried into surgery when she reached the hospital and an critical surgical delivery saved her and her son, Muwais.

Chad previously recorded the world’s second most severe maternal mortality rate before the recent arrival of refugees, but the conditions endured by the Sudanese place additional women in risk.

At the hospital, where they have birthed 824 babies in frequently urgent circumstances this year, the doctors are able to help plenty, but it is what affects the women who are cannot access the hospital that alarms the professionals.

In the 24 months since the domestic strife in Sudan started, the vast majority of the refugees who have arrived and stayed in Chad are females and minors. In total, about one point two million Sudanese are being sheltered in the east of the country, 400,000 of whom fled the previous conflict in Darfur.

Chad has hosted the bulk of the millions of people who have escaped 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 men have not left to be close to homes and land; many were slain, captured or made to join the conflict. Those of employable age move on quickly from Chad’s desolate refugee camps to find work in the main city, N’Djamena, or further, in nearby Libya.

It means women are stranded, without the resources to provide for the children and the elderly left in their care. To avoid overcrowding near the border, the Chadian government has relocated people to less crowded encampments such as Metche with average populations of about 50,000, but in isolated regions with no services and scarce prospects.

Metche has a hospital established by a medical aid organization, which began as a few tents but has developed to contain an procedure area, but little else. There is unemployment, families must walk hours to find burning material, and each person must survive on about nine litres of water a day – well under the suggested amount.

This seclusion means hospitals are admitting women with problems in their pregnancy at a critical stage. There is only a sole emergency vehicle to cover the route between the Metche hospital and the medical tent near the camp at Alacha, where Mohammed is one of close to fifty thousand refugees. The medical team has seen cases where women in extreme agony have had to endure a full night for the ambulance to come.

Imagine being in the final trimester, in childbirth, and making a lengthy trip on a cart pulled by a donkey to get to a clinic

As well as being uneven, the road traverses valleys that fill with water during the monsoon, 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 challenging travels to the hospital by foot or on a donkey.

“Imagine being about to give birth, in labour, and journeying for an extended time on a animal-drawn vehicle to get to a medical center. The primary issue is the delay but having to arrive under such circumstances also has an effect on the delivery,” says the surgeon.

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

Mohammed has continued under care in the couple of months since her C-section. Experiencing malnutrition, she developed an infection, while her son has been closely watched. The parent has gone to other towns in seek jobs, so Mohammed is entirely leaning on her mother.

The nutritional care section has grown 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, creating remedies and assessing weights on a instrument created using a pail and cord.

In mild cases children get packets of PlumpyNut, the specifically created 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 infant son, Sufian Sulaiman, is being nourished via a nose tube. The child has been sick for the past year but Abubakar was only provided with painkillers without any diagnosis, until she made the travel from Alacha to Metche.

“Every day, I see additional kids arriving in this structure,” she says. “The food we’re eating is inadequate, there’s insufficient food and it’s not nutritious.

“If we were at home, we could’ve coped better. You can go and grow crops, you can find employment, but here we’re reliant on what we’re distributed.”

And what they are given is a meager portion of cereal, vegetable oil and salt, distributed every couple of months. Such a basic diet is deficient in nutrients, and the little cash she is given purchases very little in the weekly food markets, where values have increased.

Abubakar was relocated to Alacha after coming from Sudan in 2023, having run from the militia Rapid Support Forces’ raid on her home city of El Geneina in June that year.

Failing to secure jobs in Chad, her husband has left for Libya in the hope of gathering adequate cash for them to join him. She lives with his relatives, distributing whatever food they can get.

Abubakar says she has already witnessed food supplies decreasing and there are fears that the sharp decreases in overseas aid budgets by the US, UK and other European countries, could make things worse. Despite the war in Sudan having produced the 21st century’s most severe crisis and the {scale of needs|extent