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For an extended period, travelling roughly on the waterlogged dirt track to the medical facility, 18-year-old Makka Ibraheem Mohammed gripped firmly to her seat and focused on stopping herself being sick. She was in childbirth, in severe suffering 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 hundreds of thousands of Sudanese people who ran to Chad since 2023, living hand to mouth in this difficult terrain, are women. They reside in secluded encampments in the desert with limited water and food, no work and with treatment often a dangerously far away.

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

“I kept getting infections during my term and I had to go the medical tent on numerous visits – when I was there, the delivery commenced. But I wasn’t able to give birth without intervention because my uterus had collapsed,” says Mohammed. “I had to wait two hours for the ambulance but all I recall is the pain; 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 hurried into surgery when she arrived at the hospital and an urgent C-section preserved the lives of her and her son, Muwais.

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

At the hospital, where they have birthed 824 babies in often critical situations this year, the medical staff are able to help plenty, but it is what happens to the women who are not able to reach the hospital that alarms the professionals.

In the couple of years since the civil war in Sudan started, 86% of the refugees who have arrived and stayed in Chad are females and minors. In total, about one point two million Sudanese are being sheltered in the east of the country, a large number of whom ran from the previous conflict in Darfur.

Chad has taken the lion’s share of the millions of people who have escaped the war in Sudan; others have gone to South Sudan, Egypt and Ethiopia. A total of millions of Sudanese have been forced out of their homes.

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

It implies women are stranded, without the resources to sustain the children and the elderly left in their charge. To prevent congestion near the border, the Chadian government has transferred refugees to smaller camps such as Metche with usual resident counts of about a large community, but in isolated regions with no services and few opportunities.

Metche has a hospital established by a medical aid organization, which began as a few tents but has expanded to include an surgical room, but not much more. There is a lack of jobs, families must journey for extended periods to find fuel, and each person must subsist with about a small amount of water a day – well under the suggested amount.

This remoteness means hospitals are receiving women with issues in their pregnancy when it is almost too late. There is only a single ambulance to travel the path between the Metche hospital and the medical tent near the camp at Alacha, where Mohammed is one of nearly 50,000 refugees. The medical team has observed instances where women in desperate pain have had to wait an entire night for the ambulance to reach them.

Imagine being expecting a child, in childbirth, and making a lengthy trip on a animal-drawn transport to get to a hospital

As well as being uneven, the road traverses valleys that fill with water during the wet period, completely blocking travel.

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

“Imagine being about to give birth, in labour, and making a long trip on a cart pulled by a donkey to get to a clinic. The biggest factor is the lag but having to arrive under such circumstances also has an impact on the delivery,” says the surgeon.

Undernourishment, which is on the rise, also elevates the likelihood of problems in pregnancy, including the uterine ruptures that medical staff often encounter.

Mohammed has remained in hospital in the 60 days since her C-section. Suffering from malnutrition, she got sick, while her son has been closely watched. The father has travelled to other towns in look for employment, so Mohammed is totally dependent on her mother.

The nutritional care section has expanded to six tents and has patients spilling over into other sections. Children are placed under mosquito nets in sweltering heat in almost total quiet as doctors and nurses work, preparing treatments and assessing weights on a scale made from a container and string.

In mild cases children get packets of PlumpyNut, the specially formulated peanut paste, but the worst cases need a consistent supply of enriched milk. Mohammed’s baby is fed his through a syringe.

Suhayba Abdullah Abubakar’s 11-month-old boy, Sufian Sulaiman, is being fed through a nasal drip. The child has been unwell 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 further minors joining us in this structure,” she says. “The nutrition we receive is low-quality, there’s too little nourishment and it’s not nutritious.

“If we were at home, we could’ve adapted ourselves. You can go and cultivate plants, you can get a job, but here we’re reliant on what we’re given.”

And what they are given is a meager portion of grain, edible oil and salt, handed out every couple of months. Such a minimal nutrition is deficient in nutrients, and the little cash she is given purchases very little in the local bazaars, where costs have risen.

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

Unable to get employment in Chad, her husband has traveled to Libya in the desire to gathering adequate cash for them to join him. She resides with his family members, dividing up whatever nourishment they obtain.

Abubakar says she has already witnessed food supplies decreasing and there are fears that the sharp decreases in international assistance funds by the US, UK and other European countries, could deteriorate conditions. Despite the war in Sudan having produced the 21st century’s worst humanitarian disaster and the {scale of needs|extent