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For an extended period, jolting along the flooded dirt track to the medical facility, 18-year-old Makka Ibraheem Mohammed held on tight to her seat and focused on stopping herself throwing up. She was in delivery, in severe suffering after her uterine wall split, but was now being shaken violently in the ambulance that lurched across 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, living hand to mouth in this harsh landscape, are females. They live in remote settlements in the desert with scarce resources, no work and with healthcare often a life-threateningly long distance away.

The medical center Mohammed needed was in Metche, another refugee camp more than a considerable journey away.

“I continuously experienced infections during my term and I had to go the clinic seven times – when I was there, the delivery commenced. But I could not give birth without intervention because my uterus had collapsed,” says Mohammed. “I had to remain for 120 minutes for the ambulance but all I can think of the suffering; it was so unbearable I became delirious.”

Her parent, Ashe Khamis Abdullah, 40, feared she would suffer the death of her child and grandchild. But Mohammed was hurried into surgery when she got to the hospital and an urgent C-section preserved the lives of her and her son, Muwais.

Chad previously recorded the world’s second worst maternal death rate before the current influx of refugees, but the circumstances suffered by the Sudanese put even more women in danger.

At the hospital, where they have assisted in the arrival of 824 babies in often critical situations this year, the medics are able to save many, but it is what occurs with the women who are cannot access the hospital that concerns them.

In the two years since the civil war in Sudan erupted, over four-fifths of the displaced persons who came and settled in Chad are females and minors. In total, about over a million Sudanese are being sheltered in the eastern part of the country, 400,000 of whom ran from the past violence 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 uprooted from their homes.

Many males have not left to be in proximity to homes and land; some were killed, taken hostage or forced into fighting. Those of working age rapidly leave from Chad’s desolate refugee camps to look for jobs in the capital, N’Djamena, or elsewhere, in adjacent Libya.

It implies women are stranded, without the ability to feed the young and old left in their care. To reduce density near the border, the Chadian government has transferred refugees to more compact settlements such as Metche with usual resident counts of about a large community, but in distant locations with few facilities and few opportunities.

Metche has a hospital established by a medical aid organization, which was initially a few tents but has grown to feature an procedure area, but little else. There is unemployment, families must travel long distances to find fuel, and each person must subsist with about a small amount of water a day – far below the suggested amount.

This isolation means hospitals are admitting women with problems in their pregnancy when it is almost too late. There is only a single ambulance to cover the route between the Metche hospital and the medical tent near the settlement of Alacha, where Mohammed is one of nearly 50,000 refugees. The medical team has observed instances where women in severe suffering have had to remain overnight for the ambulance to come.

Imagine being expecting a child, in delivery, and travelling hours on a animal-drawn transport to get to a hospital

As well as being bumpy, the road traverses valleys that fill with water during the rainy season, completely preventing travel.

A surgeon at the hospital in Metche said all the situations she encounters is an emergency, with some women having to make challenging travels to the hospital by walking or on a mule.

“Imagine being about to give birth, in labour, and journeying for an extended time on a cart pulled by a donkey to get to a hospital. The main problem is the delay but having to travel in this state also has an influence on the childbirth,” says the surgeon.

Poor nutrition, which is growing, also elevates the likelihood of complications in pregnancy, including the uterine ruptures that medical staff see regularly.

Mohammed has remained in hospital in the 60 days since her caesarean. Afflicted by malnutrition, she developed an infection, while her son has been regularly checked. The male guardian has gone to other towns in search of work, so Mohammed is completely reliant on her mother.

The nutritional care section has expanded to six tents and has individuals overflowing into other sections. Children rest beneath mosquito nets in extreme warmth in almost total quiet as medical staff work, preparing treatments and assessing weights on a instrument created using a pail and cord.

In moderate instances children get sachets of PlumpyNut, the uniquely designed peanut paste, but the critical situations need a consistent supply of nutrient-rich liquid. Mohammed’s baby is fed his through a medical device.

Suhayba Abdullah Abubakar’s infant son, Sufian Sulaiman, is being nourished via a nose tube. The baby has been ill for the past year but Abubakar was consistently offered just painkillers without any diagnosis, until she made the journey from Alacha to Metche.

“Every day, I see more children joining us in this structure,” she says. “The food we’re eating is inadequate, there’s too little nourishment and it’s deficient in vitamins.

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

And what they are given is a limited quantity of grain, vegetable oil and salt, provided every 60 days. Such a simple food is deficient in nutrients, and the meager funds she is given acquires minimal items in the local bazaars, where costs have risen.

Abubakar was transferred to Alacha after coming from Sudan in 2023, having fled the armed group Rapid Support Forces’ attack on her home city 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 family members, sharing out whatever food they can get.

Abubakar says she has already seen food distributions being reduced and there are concerns 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