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For an extended period, bouncing over the soggy dirt track to the clinic, 18-year-old Makka Ibraheem Mohammed gripped firmly to her seat and tried hard stopping herself being sick. She was in delivery, in extreme pain after her uterine wall split, but was now being tossed around in the ambulance that bumped over the potholes and ridges of the road through the Chadian desert.

Most of the hundreds of thousands of Sudanese refugees who have fled to Chad since 2023, barely getting by in this inhospitable environment, are women. They live in secluded encampments in the desert with insufficient supplies, little employment and with medical help often a life-threateningly long distance away.

The medical center Mohammed needed was in Metche, one more encampment more than two hours away.

“I continuously experienced infections during my pregnancy and I had to go the health post seven times – when I was there, the labour began. But I wasn’t able to give birth without intervention because my uterus had collapsed,” says Mohammed. “I had to wait two hours for the ambulance but all I remember was the suffering; it was so unbearable I became disoriented.”

Her mother, 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 rescued her and her son, Muwais.

Chad already had the world’s second most severe maternal fatality statistic before the current influx of refugees, but the situations faced by the Sudanese expose further women in risk.

At the hospital, where they have delivered 824 babies in frequently urgent circumstances this year, the medical staff are able to help plenty, but it is what happens to the women who are fail to get to the hospital that alarms the professionals.

In the two years since the domestic strife in Sudan started, the vast majority of the displaced persons who came and settled in Chad are mothers and kids. In total, about 1.2 million Sudanese are being sheltered in the eastern region of the country, 400,000 of whom escaped the earlier war in Darfur.

Chad has taken the lion’s share of the over four million people who have fled 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 men have stayed behind to be near homes and land; many were killed, captured or made to join the conflict. Those of working age move on quickly from Chad’s desolate refugee camps to look for jobs in the main city, N’Djamena, or beyond, in neighbouring Libya.

It means women are stranded, without the ability to sustain the dependents left in their responsibility. To prevent congestion near the border, the Chadian government has moved individuals to less crowded encampments such as Metche with usual resident counts of about 50,000, but in distant locations with no services and minimal chances.

Metche has a hospital set up by a medical aid organization, which began as a few tents but has developed to contain an operating theatre, but few additional amenities. There is no work, families must journey for extended periods to find burning material, and each person must survive on about minimal water of water a day – far below the recommended 20 litres.

This seclusion means hospitals are receiving women with complications in their pregnancy at a critical stage. There is only a sole emergency vehicle to travel the path between the Metche hospital and the health post near the settlement of Alacha, where Mohammed is one of a large number of refugees. The medical team has observed instances where women in extreme agony have had to endure a full night for the ambulance to come.

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

As well as being bumpy, the route passes through valleys that fill with water during the monsoon, completely cutting off travel.

A surgeon at the hospital in Metche said each patient she treats is an critical situation, with some women having to make long and difficult journeys to the hospital by walking or on a pack animal.

“Imagine being in the late stages of pregnancy, in labour, and journeying for an extended time on a animal-drawn vehicle to get to a clinic. The main problem is the lag but having to come in these conditions also has an impact on the delivery,” says the surgeon.

Malnutrition, which is on the rise, also elevates the likelihood of complications in pregnancy, including the womb tears that medical staff see regularly.

Mohammed has remained in hospital in the 60 days since her caesarean. Experiencing malnutrition, she developed an infection, while her son has been carefully monitored. The father has gone to other towns in search of work, so Mohammed is entirely leaning on her mother.

The nutritional care section has increased to six tents and has patients spilling over into other sections. Children are placed under mosquito nets in sweltering heat in almost total quiet as medical staff work, mixing medications and weighing children on a device constructed from a bucket and rope.

In less severe situations children get small bags of PlumpyNut, the specially formulated peanut paste, but the critical situations need a regular intake of fortified formula. Mohammed’s baby is administered his nutrition through a medical device.

Suhayba Abdullah Abubakar’s 11-month-old boy, Sufian Sulaiman, is being fed through a nasal drip. The child has been sick for the past year but Abubakar was repeatedly given only painkillers without any medical assessment, until she made the travel from Alacha to Metche.

“Every day, I see more children joining us in this tent,” she says. “The meals we consume is low-quality, there’s not enough to eat and it’s deficient in vitamins.

“If we were at home, we could’ve adjusted our lives. You can go and farm produce, you can find employment, but here we’re dependent on what we’re distributed.”

And what they are provided is a limited quantity of sorghum, edible oil and salt, provided every couple of months. Such a minimal nutrition is deficient in nutrients, and the small amount of money she is given cannot buy much in the weekly food markets, where costs have risen.

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

Unable to get employment in Chad, her spouse has left for Libya in the hope of gathering adequate cash for them to come later. She stays with his kin, distributing whatever meals they acquire.

Abubakar says she has already seen food distributions being reduced and there are fears that the sharp decreases in foreign support money by the US, UK and other European countries, could make things worse. Despite the war in Sudan having produced the 21st century’s gravest emergency and the {scale of needs|extent