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For hours, travelling roughly on the soggy dirt track to the clinic, 18-year-old Makka Ibraheem Mohammed gripped firmly to her seat and tried hard stopping herself throwing up. She was in delivery, in agonizing discomfort after her uterine wall split, but was now being shaken violently in the ambulance that lurched across the dips and bumps of the road through the Chadian desert.

Most of the close to a million Sudanese refugees who have fled to Chad since 2023, surviving precariously in this difficult terrain, are females. They stay in remote settlements in the desert with scarce resources, few job opportunities and with medical help often a dangerously far away.

The clinic Mohammed needed was in Metche, a different settlement more than 120 minutes away.

“I kept getting infections during my gestation and I had to go the health post multiple occasions – when I was there, the pregnancy started. But I could not give birth normally because my uterine muscles failed,” says Mohammed. “I had to remain for 120 minutes for the ambulance but all I can think of the agony; it was so intense I became delirious.”

Her maternal figure, Ashe Khamis Abdullah, 40, feared she would be bereft of her daughter and baby grandson. But Mohammed was rushed straight into surgery when she got to the hospital and an critical surgical delivery saved her and her son, Muwais.

Chad already had the world’s second most severe maternal mortality rate before the ongoing stream of refugees, but the conditions endured by the Sudanese place additional women in risk.

At the hospital, where they have assisted in the arrival of 824 babies in mostly emergency conditions this year, the doctors 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 24 months since the domestic strife in Sudan began, 86% of the refugees who have arrived and settled in Chad are women and children. In total, about over a million Sudanese are being hosted in the east of the country, a large number of whom fled the past violence in Darfur.

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

Many adult men have remained to be close to homes and land; some were slain, captured or made to join the conflict. Those of working age soon depart from Chad’s isolated encampments to look for jobs in the capital, N’Djamena, or beyond, in adjacent Libya.

It results in women are stranded, without the resources to provide for the young and old left in their responsibility. To reduce density near the border, the Chadian government has relocated people to smaller camps such as Metche with average populations of about 50,000, but in distant locations with few facilities and few opportunities.

Metche has a hospital established by a medical aid organization, which began as a few tents but has developed to contain an operating theatre, but not much more. There is a lack of jobs, families must walk hours to find firewood, and each person must survive on about minimal water of water a day – far below the suggested amount.

This remoteness means hospitals are admitting women with issues 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 a large number of refugees. The medical team has seen cases where women in desperate pain have had to remain overnight for the ambulance to reach them.

Imagine being in the final trimester, in labour, and journeying for a long time on a cart pulled by a donkey to get to a medical facility

As well as being rough, the route passes through valleys that become inundated during the rainy season, completely blocking travel.

A surgeon at the hospital in Metche said each patient she treats is an crisis, with some women having to make arduous trips to the hospital by foot or on a donkey.

“Imagine being nine months pregnant, in delivery, and making a long trip on a animal-drawn vehicle to get to a hospital. The primary issue is the wait but having to come in these conditions also has an effect on the childbirth,” says the surgeon.

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

Mohammed has continued under care in the two months since her caesarean. Afflicted by malnutrition, she contracted an illness, while her son has been closely watched. The father has gone to other towns in search of work, so Mohammed is completely reliant 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 extreme warmth in almost total quiet as doctors and nurses work, creating remedies and weighing children on a instrument created using a pail and cord.

In less severe situations children get small bags of PlumpyNut, the specially formulated peanut paste, but the worst cases need a regular intake of enriched milk. Mohammed’s baby is fed his through a medical device.

Suhayba Abdullah Abubakar’s infant son, Sufian Sulaiman, is being fed through a nasal drip. The child has been sick for the past year but Abubakar was consistently offered just painkillers without any medical assessment, until she made the journey from Alacha to Metche.

“Every day, I see additional kids coming in in this structure,” she says. “The nutrition we receive is inadequate, there’s insufficient food and it’s deficient in vitamins.

“If we were at home, we could’ve adjusted our lives. You can go and cultivate plants, you can find employment, but here we’re reliant on what we’re given.”

And what they are provided is a meager portion of sorghum, edible oil and salt, distributed every two months. Such a basic diet lacks nutrition, and the meager funds she is given purchases very little in the weekly food markets, where prices have become inflated.

Abubakar was moved to Alacha after reaching from Sudan in 2023, having escaped the militia Rapid Support Forces’ raid on her native town of El Geneina in June that year.

Failing to secure jobs in Chad, her partner has gone to Libya in the hope of earning sufficient funds for them to follow. She stays with his kin, dividing up whatever nourishment they obtain.

Abubakar says she has already observed food rations being cut and there are fears that the abrupt cuts in foreign support money by the US, UK and other European countries, could deteriorate conditions. Despite the war in Sudan having caused the 21st century’s worst humanitarian disaster and the {scale of needs|extent