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For an extended period, bouncing over the waterlogged dirt track to the clinic, 18-year-old Makka Ibraheem Mohammed held on tight to her seat and concentrated on stopping herself being sick. She was in childbirth, in severe suffering after her uterine wall split, but was now being tossed around in the ambulance that jumped along the potholes and ridges of the road through the Chadian desert.

Most of the 878,000 Sudanese refugees who have fled to Chad since 2023, barely getting by in this harsh landscape, are women. They live in remote settlements in the desert with scarce resources, few job opportunities and with treatment often a life-threateningly long distance away.

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

“I repeatedly suffered from infections during my gestation and I had to go the clinic on numerous visits – when I was there, the delivery commenced. But I wasn’t able to give birth without intervention because my womb had given way,” says Mohammed. “I had to wait two hours for the ambulance but all I can think of the suffering; it was so intense I became confused.”

Her mother, Ashe Khamis Abdullah, 40, feared she would lose both her daughter and baby grandson. But Mohammed was immediately taken for surgery when she got to the hospital and an urgent C-section rescued her and her son, Muwais.

Chad previously recorded the world’s second-highest maternal mortality rate before the ongoing stream of refugees, but the circumstances suffered by the Sudanese put even more women in risk.

At the hospital, where they have delivered 824 babies in frequently urgent circumstances this year, the medical staff are able to rescue numerous, but it is what happens to the women who are not able to reach the hospital that concerns them.

In the couple of years since the domestic strife in Sudan began, the vast majority of the refugees who have arrived and settled in Chad are females and minors. In total, about 1.2 million Sudanese are being hosted in the eastern part of the country, 400,000 of whom ran from the earlier war in Darfur.

Chad has taken the lion’s share of the millions of people who have run from the war in Sudan; some have travelled to South Sudan, Egypt and Ethiopia. A total of 11.8 million Sudanese have been uprooted from their homes.

Many men have remained to be near homes and land; some were slain, abducted or forced into fighting. Those of employable age rapidly leave from Chad’s barren settlements to seek employment in the capital, N’Djamena, or further, in adjacent Libya.

It results in women are stranded, without the resources to provide for the children and the elderly left in their charge. To prevent congestion near the border, the Chadian government has moved individuals to less crowded encampments such as Metche with average populations of about 50,000, but in distant locations with no services and few opportunities.

Metche has a hospital set up by a medical aid organization, which was initially a few tents but has grown to feature an operating theatre, but not much more. There is no work, families must walk hours to find burning material, and each person must get by with about minimal water of water a day – much less than the suggested amount.

This remoteness means hospitals are treating women with issues in their pregnancy at a critical stage. There is only a single ambulance to cover the route between the Metche hospital and the clinic near the Alacha encampment, where Mohammed is one of a large number of refugees. The medical team has seen cases where women in desperate pain have had to endure a full night for the ambulance to come.

Imagine being expecting a child, in childbirth, and making a lengthy trip on a cart pulled by a donkey to get to a hospital

As well as being uneven, the route passes through valleys that become inundated during the monsoon, completely blocking travel.

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

“Imagine being nine months pregnant, in labour, and travelling hours on a animal-drawn vehicle to get to a clinic. The biggest factor is the wait but having to come in these conditions also has an impact on the birth,” says the surgeon.

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

Mohammed has remained in hospital in the couple of months since her surgical delivery. Afflicted by malnutrition, she developed an infection, while her son has been regularly checked. The father has gone to other towns in look for employment, so Mohammed is completely reliant on her mother.

The malnutrition ward has increased to six tents and has patients spilling over into other sections. Children rest beneath mosquito nets in sweltering heat in almost total quiet as doctors and nurses work, mixing medications and weighing children on a scale made from a container and string.

In mild cases children get small bags of PlumpyNut, the specially formulated peanut paste, but the most severe instances need a regular intake of fortified formula. Mohammed’s baby is administered his nutrition through a injector.

Suhayba Abdullah Abubakar’s baby boy, Sufian Sulaiman, is being nourished via a nasal drip. The baby has been sick 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 further minors coming in in this tent,” she says. “The meals we consume is poor, there’s not enough to eat and it’s lacking in nutrients.

“If we were at home, we could’ve adjusted our lives. You can go and grow crops, you can find employment, but here we’re dependent on what we’re provided.”

And what they are provided is a limited quantity of sorghum, vegetable oil and salt, handed out every 60 days. Such a basic diet offers little sustenance, and the meager funds she is given acquires minimal items in the regular markets, where prices have become inflated.

Abubakar was relocated to Alacha after coming from Sudan in 2023, having escaped the armed group 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 gathering adequate cash for them to follow. She stays with his family members, sharing out whatever meals they acquire.

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