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For a long time, jolting along the flooded dirt track to the clinic, 18-year-old Makka Ibraheem Mohammed held on tight to her seat and tried hard stopping herself throwing up. She was in childbirth, in extreme pain after her womb tore, but was now being tossed around in the ambulance that bumped over the uneven terrain of the road through the Chadian desert.

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

The hospital Mohammed needed was in Metche, one more encampment more than a considerable journey away.

“I repeatedly suffered from infections during my gestation 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 endure a long delay for the ambulance but all I can think of the agony; it was so bad I became delirious.”

Her parent, Ashe Khamis Abdullah, 40, worried she would lose both her offspring and descendant. But Mohammed was immediately taken for surgery when she arrived at the hospital and an urgent C-section saved her and her son, Muwais.

Chad already had the world’s second-highest maternal fatality statistic before the current influx of refugees, but the circumstances suffered by the Sudanese expose further women in peril.

At the hospital, where they have assisted in the arrival of 824 babies in often critical situations 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 concerns them.

In the two years since the civil war in Sudan started, over four-fifths of the refugees who have arrived and remained in Chad are women and children. In total, about 1.2 million Sudanese are being hosted in the eastern region of the country, 400,000 of whom ran from the previous conflict in Darfur.

Chad has hosted the bulk of the 4.1 million people who have fled the war in Sudan; the remainder moved 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 near homes and land; many were murdered, taken hostage or forced into fighting. Those of adult age soon depart from Chad’s desolate refugee camps to find work in the capital, N’Djamena, or further, in adjacent Libya.

It means women are left alone, 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 transferred refugees to less crowded encampments such as Metche with typical numbers of about a large community, but in distant locations with few facilities and minimal chances.

Metche has a hospital established by a medical aid organization, which was initially a few tents but has developed to contain an surgical room, but not much more. There is a lack of jobs, families must walk hours to find fuel, and each person must get by with about minimal water of water a day – much less than the recommended 20 litres.

This seclusion means hospitals are receiving women with complications 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 camp at Alacha, where Mohammed is one of nearly 50,000 refugees. The medical team has encountered situations where women in severe suffering have had to wait an entire night for the ambulance to reach them.

Imagine being nine months pregnant, in labour, and travelling hours on a cart pulled by a donkey to get to a medical facility

As well as being bumpy, the route passes through valleys that flood during the rainy season, 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 arduous trips to the hospital by on foot or on a mule.

“Imagine being nine months pregnant, in delivery, and travelling hours on a cart pulled by a donkey to get to a clinic. The main problem is the lag but having to arrive under such circumstances also has an impact on the childbirth,” says the surgeon.

Undernourishment, which is growing, also elevates the likelihood of complications in pregnancy, including the uterine splits that medical staff frequently observe.

Mohammed has continued under care in the two months since her caesarean. Experiencing malnutrition, she got sick, while her son has been carefully monitored. The parent has travelled to other towns in search of work, so Mohammed is completely reliant on her mother.

The nutritional care section has increased to six tents and has individuals overflowing into other sections. Children rest beneath mosquito nets in extreme warmth in almost utter stillness as doctors and nurses work, preparing treatments and weighing children on a instrument created using a bucket and rope.

In less severe situations children get packets of PlumpyNut, the uniquely designed peanut paste, but the critical situations need a daily dose 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 nourished via a nose tube. The infant has been unwell for the past year but Abubakar was consistently offered just painkillers without any identification, until she made the journey from Alacha to Metche.

“Every day, I see more children joining us in this shelter,” she says. “The food we’re eating 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 grow crops, you can work to earn some money, but here we’re dependent on what we’re provided.”

And what they are allocated is a meager portion of cereal, cooking oil and salt, provided every two months. Such a simple food is deficient in nutrients, and the little cash she is given purchases very little in the local bazaars, where costs have risen.

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

Unable to get employment in Chad, her husband has left for Libya in the hope of earning sufficient funds for them to come later. She lives with his relatives, dividing up whatever meals they acquire.

Abubakar says she has already observed food distributions being reduced and there are fears that the sudden reductions in overseas aid budgets by the US, UK and other European countries, could worsen the situation. Despite the war in Sudan having caused the 21st century’s most severe crisis and the {scale of needs|extent