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For a long time, bouncing over the flooded dirt track to the clinic, 18-year-old Makka Ibraheem Mohammed clung desperately to her seat and concentrated on stopping herself vomiting. She was in childbirth, in agonizing discomfort after her uterus ruptured, 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 close to a million Sudanese refugees who have fled to Chad since 2023, living hand to mouth in this inhospitable environment, are women. They stay in secluded encampments in the desert with scarce resources, little employment and with treatment often a perilously remote away.

The clinic Mohammed needed was in Metche, another refugee camp more than 120 minutes away.

“I continuously experienced infections during my gestation and I had to go the clinic multiple occasions – when I was there, the pregnancy started. 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 can think of the pain; it was so bad I became disoriented.”

Her parent, Ashe Khamis Abdullah, 40, was terrified she would be bereft of her offspring and descendant. But Mohammed was rushed straight into surgery when she arrived at the hospital and an critical surgical delivery rescued her and her son, Muwais.

Chad previously recorded the world’s second-highest maternal mortality rate before the recent arrival of refugees, but the circumstances suffered by the Sudanese expose further women in risk.

At the hospital, where they have delivered 824 babies in mostly emergency conditions this year, the medical staff are able to save many, but it is what occurs with the women who are fail to get to the hospital that worries the staff.

In the 24 months since the civil war in Sudan erupted, over four-fifths of the refugees who have arrived and settled in Chad are females and minors. In total, about over a million Sudanese are being sheltered in the eastern region of the country, 400,000 of whom fled the earlier war in Darfur.

Chad has taken the lion’s share of the 4.1 million 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 males have not left to be near homes and land; others have been killed, abducted or forced into fighting. Those of working age soon depart from Chad’s barren settlements to seek employment in the capital, N’Djamena, or elsewhere, in adjacent Libya.

It means women are left alone, without the means to sustain the dependents left in their charge. To prevent congestion near the border, the Chadian government has moved individuals to less crowded encampments such as Metche with typical numbers of about fifty thousand, but in remote areas with no services and few opportunities.

Metche has a hospital set up by a medical aid organization, which started off as a few tents but has expanded to include an procedure area, but not much more. There is no work, families must journey for extended periods to find firewood, and each person must subsist with about nine litres of water a day – well under the advised quantity.

This seclusion means hospitals are receiving women with issues in their pregnancy dangerously late. There is only a one medical transport to serve the area between the Metche hospital and the health post near the Alacha encampment, where Mohammed is one of nearly 50,000 refugees. The medical team has observed instances where women in severe suffering have had to wait an entire night for the ambulance to come.

Imagine being in the final trimester, in childbirth, and travelling hours 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 cutting off travel.

A surgeon at the hospital in Metche said every case she sees is an emergency, with some women having to make challenging travels to the hospital by on foot or on a pack animal.

“Imagine being in the late stages of pregnancy, in delivery, and making a long trip on a cart pulled by a donkey to get to a clinic. The biggest factor is the wait but having to come in these conditions also has an impact on the delivery,” says the surgeon.

Malnutrition, which is increasing, also increases the risk of problems in pregnancy, including the womb tears that medical staff often encounter.

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 travelled to other towns in look for employment, so Mohammed is completely reliant on her mother.

The malnutrition ward has grown to six tents and has patients spilling over into other sections. Children rest beneath mosquito nets in sweltering heat in almost complete silence as doctors and nurses work, preparing treatments and weighing children on a scale made from a pail and cord.

In less severe situations children get small bags of PlumpyNut, the uniquely designed peanut paste, but the most severe instances need a daily dose of fortified formula. Mohammed’s baby is given his nourishment through a medical device.

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

“Every day, I see further minors joining us in this shelter,” she says. “The food we’re eating is poor, there’s not enough to eat and it’s lacking in nutrients.

“If we were at home, we could’ve adapted ourselves. You can go and grow crops, you can find employment, but here we’re dependent on what we’re given.”

And what they are provided is a limited quantity of grain, cooking oil and salt, distributed every 60 days. Such a minimal nutrition is deficient in nutrients, and the little cash she is given purchases very little in the regular markets, where values have increased.

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

Unable to get employment in Chad, her partner has traveled to Libya in the aspiration to gathering adequate cash for them to follow. She resides with his relatives, dividing up whatever food they can get.

Abubakar says she has already witnessed food rations being cut and there are concerns that the abrupt cuts 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 worst humanitarian disaster and the {scale of needs|extent