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For an extended period, jolting along the flooded dirt track to the clinic, 18-year-old Makka Ibraheem Mohammed clung desperately to her seat and focused on stopping herself throwing up. She was in labour, in severe suffering after her womb tore, but was now being shaken violently in the ambulance that bumped over the potholes and ridges of the road through the Chadian desert.

Most of the 878,000 Sudanese people who ran to Chad since 2023, surviving precariously in this inhospitable environment, are females. They stay in remote settlements in the desert with insufficient supplies, few job opportunities and with healthcare often a perilously remote away.

The medical center Mohammed needed was in Metche, a different settlement more than two hours away.

“I repeatedly suffered from infections during my term and I had to go the medical tent seven times – when I was there, the pregnancy started. But I found it impossible to give birth normally because my uterine muscles failed,” says Mohammed. “I had to endure a long delay for the ambulance but all I can think of the suffering; it was so intense I became disoriented.”

Her mother, Ashe Khamis Abdullah, 40, was terrified she would suffer the death of her offspring and descendant. But Mohammed was rushed straight into surgery when she reached the hospital and an urgent C-section saved her and her son, Muwais.

Chad was known for the world’s second-highest maternal death rate before the recent arrival of refugees, but the situations faced by the Sudanese place additional women in danger.

At the hospital, where they have assisted in the arrival of 824 babies in frequently urgent circumstances this year, the medical staff are able to save many, but it is what occurs with the women who are cannot access the hospital that worries the staff.

In the 24 months since the internal conflict in Sudan erupted, 86% of the displaced persons who came and remained in Chad are mothers and kids. In total, about over a million Sudanese are being accommodated in the eastern region of the country, 400,000 of whom escaped the earlier war in Darfur.

Chad has accepted the majority 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 11.8 million Sudanese have been displaced from their homes.

Many adult men have remained to be close to homes and land; others have been slain, abducted or conscripted. Those of working age move on quickly from Chad’s desolate refugee camps to find work in the capital, N’Djamena, or beyond, in nearby Libya.

It results in women are stranded, without the resources to feed the dependents left in their care. To prevent congestion near the border, the Chadian government has relocated people to more compact settlements such as Metche with average populations of about fifty thousand, but in isolated regions with no services and scarce prospects.

Metche has a hospital built by a medical aid organization, which started off as a few tents but has grown to feature an procedure area, but little else. There is unemployment, families must walk hours to find fuel, and each person must subsist with about minimal water of water a day – far below the advised quantity.

This isolation means hospitals are receiving women with problems in their pregnancy when it is almost too late. There is only a single ambulance to travel the path between the Metche hospital and the health post near the settlement of Alacha, where Mohammed is one of close to fifty thousand refugees. The medical team has observed instances where women in severe suffering have had to endure a full night for the ambulance to arrive.

Imagine being in the final trimester, in labour, and travelling hours on a animal-drawn transport to get to a clinic

As well as being uneven, the path goes through valleys that flood during the wet period, 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 pack animal.

“Imagine being in the late stages of pregnancy, in delivery, and journeying for an extended time on a cart pulled by a donkey to get to a hospital. The biggest factor is the lag but having to arrive under such circumstances also has an influence on the birth,” says the surgeon.

Undernourishment, which is increasing, also increases the risk of problems in pregnancy, including the uterine ruptures that medical staff often encounter.

Mohammed has stayed at the medical facility in the 60 days since her C-section. Experiencing malnutrition, she got sick, while her son has been closely watched. The father has journeyed to other towns in seek jobs, so Mohammed is totally dependent on her mother.

The undernourishment unit has increased to six tents and has cases exceeding capacity into other sections. Children are placed under mosquito nets in extreme warmth in almost utter stillness as doctors and nurses work, preparing treatments and weighing children on a device constructed from a pail and cord.

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

Suhayba Abdullah Abubakar’s baby boy, Sufian Sulaiman, is being fed through a nasal drip. The baby has been ill 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 structure,” she says. “The food we’re eating is poor, there’s too little nourishment and it’s not nutritious.

“If we were at home, we could’ve coped better. You can go and cultivate plants, you can work to earn some money, but here we’re dependent on what we’re provided.”

And what they are provided is a meager portion of grain, edible oil and salt, distributed every two months. Such a basic diet is deficient in nutrients, and the meager funds she is given cannot buy much in the regular markets, where prices have become inflated.

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

Unable to get employment in Chad, her husband has left for Libya in the hope of raising enough money for them to come later. She resides with his relatives, dividing up whatever meals they acquire.

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