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For an extended period, bouncing over the soggy dirt track to the medical facility, 18-year-old Makka Ibraheem Mohammed held on tight to her seat and focused on stopping herself being sick. She was in delivery, in agonizing discomfort after her womb tore, but was now being jostled relentlessly in the ambulance that bumped over the uneven terrain of the road through the Chadian desert.

Most of the 878,000 Sudanese displaced persons who escaped to Chad since 2023, barely getting by in this harsh landscape, are females. They reside in remote settlements in the desert with scarce resources, little employment and with healthcare often a life-threateningly long distance away.

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

“I kept getting infections during my pregnancy and I had to go the clinic multiple occasions – when I was there, the pregnancy started. But I wasn’t able to give birth naturally because my womb had given way,” says Mohammed. “I had to endure a long delay for the ambulance but all I recall is the suffering; it was so intense I became disoriented.”

Her mother, Ashe Khamis Abdullah, 40, worried she would lose both her daughter and baby grandson. But Mohammed was rushed straight 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-highest maternal fatality statistic before the current influx of refugees, but the situations faced by the Sudanese place additional women in peril.

At the hospital, where they have birthed 824 babies in frequently urgent circumstances this year, the medical staff are able to save many, but it is what affects the women who are cannot access the hospital that worries the staff.

In the two years since the civil war in Sudan began, 86% of the people who reached and stayed in Chad are women and children. In total, about over a million Sudanese are being sheltered in the east of the country, a large number of whom escaped the earlier war in Darfur.

Chad has hosted the bulk of the over four million people who have escaped the war in Sudan; some have travelled to South Sudan, Egypt and Ethiopia. A total of millions of Sudanese have been forced out of their homes.

Many adult men have not left to be in proximity to homes and land; others have been murdered, taken hostage or conscripted. Those of adult age soon depart from Chad’s desolate refugee camps to look for jobs in the main city, N’Djamena, or beyond, in neighbouring Libya.

It implies women are abandoned, without the means to provide for the young and old left in their charge. To reduce density near the border, the Chadian government has moved individuals to less crowded encampments such as Metche with usual resident counts of about 50,000, but in remote areas with few facilities and few opportunities.

Metche has a hospital built by a medical aid organization, which began as a few tents but has expanded to include an surgical room, but little else. There is unemployment, families must walk hours to find firewood, and each person must get by with about nine litres of water a day – far below the suggested amount.

This isolation means hospitals are admitting women with issues in their pregnancy dangerously late. There is only a single ambulance 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 observed instances where women in extreme agony have had to remain overnight for the ambulance to arrive.

Imagine being expecting a child, 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 uneven, the route passes through valleys that fill with water during the wet period, 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 foot or on a donkey.

“Imagine being nine months pregnant, in delivery, and journeying for an extended time on a donkey cart to get to a clinic. The biggest factor is the wait but having to travel in this state also has an effect on the birth,” says the surgeon.

Poor nutrition, which is growing, also increases the risk of complications in pregnancy, including the uterine splits that medical staff frequently observe.

Mohammed has continued under care in the couple of months since her surgical delivery. Suffering from malnutrition, she got sick, while her son has been closely watched. The parent has gone to other towns in seek jobs, so Mohammed is totally dependent on her mother.

The undernourishment unit has increased to six tents and has cases exceeding capacity into other sections. Children rest beneath mosquito nets in extreme warmth in almost total quiet as medical staff work, creating remedies and assessing weights on a instrument created using a bucket and rope.

In mild cases children get small bags of PlumpyNut, the specially formulated peanut paste, but the critical situations need a consistent supply of fortified formula. Mohammed’s baby is administered his nutrition through a medical device.

Suhayba Abdullah Abubakar’s 11-month-old boy, Sufian Sulaiman, is being nourished via a nasal drip. The baby has been sick for the past year but Abubakar was repeatedly given only painkillers without any identification, until she made the journey from Alacha to Metche.

“Every day, I see further minors arriving in this structure,” she says. “The food we’re eating is inadequate, there’s not enough to eat and it’s deficient in vitamins.

“If we were at home, we could’ve adjusted our lives. You can go and grow crops, you can get a job, but here we’re relying on what we’re given.”

And what they are allocated is a small amount of grain, vegetable oil and salt, provided every couple of months. Such a minimal nutrition lacks nutrition, and the little cash she is given acquires minimal items in the weekly food markets, where prices have become inflated.

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

Failing to secure jobs in Chad, her spouse has gone to Libya in the hope of gathering adequate cash for them to come later. She lives with his family members, dividing up whatever food they can get.

Abubakar says she has already witnessed food distributions being reduced and there are concerns 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 caused the 21st century’s most severe crisis and the {scale of needs|extent