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For hours, travelling roughly on the waterlogged dirt track to the hospital, 18-year-old Makka Ibraheem Mohammed held on tight to her seat and concentrated on stopping herself vomiting. She was in labour, in extreme pain after her uterine wall split, but was now being shaken violently in the ambulance that lurched across the dips and bumps of the road through the Chadian desert.

Most of the 878,000 Sudanese refugees who have fled to Chad since 2023, surviving precariously in this difficult terrain, are women. They stay in isolated camps in the desert with scarce resources, few job opportunities and with healthcare often a life-threateningly long distance away.

The hospital Mohammed needed was in Metche, one more encampment more than two hours away.

“I repeatedly suffered from infections during my gestation and I had to go the medical tent on numerous visits – when I was there, the pregnancy started. But I wasn’t able to give birth normally because my uterine muscles failed,” says Mohammed. “I had to endure a long delay for the ambulance but all I remember was the pain; it was so bad I became confused.”

Her maternal figure, Ashe Khamis Abdullah, 40, feared she would suffer the death of her child and grandchild. But Mohammed was rushed straight into surgery when she reached the hospital and an emergency caesarean section saved her and her son, Muwais.

Chad previously recorded the world’s second worst maternal fatality statistic before the current influx of refugees, but the circumstances suffered by the Sudanese place additional women in risk.

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

In the two years since the civil war in Sudan began, the vast majority of the displaced persons who came and settled in Chad are women and children. In total, about over a million Sudanese are being hosted in the east of the country, four hundred thousand of whom fled the past violence in Darfur.

Chad has hosted the bulk 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 millions of Sudanese have been uprooted from their homes.

Many men have stayed behind to be near homes and land; some were murdered, captured or forced into fighting. Those of adult age move on quickly from Chad’s isolated encampments to seek employment in the capital, N’Djamena, or beyond, in adjacent Libya.

It results in women are abandoned, without the means to provide for the children and the elderly left in their responsibility. To reduce density near the border, the Chadian government has transferred refugees to more compact settlements such as Metche with average populations of about fifty thousand, but in distant locations with few facilities and minimal chances.

Metche has a hospital set up by a medical aid organization, which started off as a few tents but has grown to feature an procedure area, but few additional amenities. There is unemployment, families must travel long distances to find burning material, and each person must get by with about a small amount of water a day – far below the suggested amount.

This seclusion means hospitals are admitting women with issues in their pregnancy dangerously late. There is only a sole emergency vehicle to serve the area between the Metche hospital and the medical tent near the Alacha encampment, where Mohammed is one of close to fifty thousand 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 childbirth, and travelling hours on a donkey-drawn vehicle to get to a medical facility

As well as being bumpy, the path goes through valleys that fill with water during the monsoon, completely cutting off travel.

A surgeon at the hospital in Metche said all the situations she encounters is an crisis, with some women having to make arduous trips to the hospital by foot or on a pack animal.

“Imagine being in the late stages of pregnancy, in delivery, and making a long trip on a animal-drawn vehicle to get to a clinic. The primary issue is the lag but having to come in these conditions also has an impact on the birth,” says the surgeon.

Undernourishment, which is growing, also raises the chance of issues in pregnancy, including the uterine splits that medical staff see regularly.

Mohammed has continued under care in the two months since her C-section. Experiencing malnutrition, she got sick, while her son has been regularly checked. The parent has gone to other towns in search of work, so Mohammed is totally dependent on her mother.

The undernourishment unit has expanded to six tents and has individuals overflowing into other sections. Children lie under mosquito nets in sweltering heat in almost complete silence as medical staff work, preparing treatments and measuring kids on a device constructed from a bucket and rope.

In moderate instances children get sachets of PlumpyNut, the specially formulated peanut paste, but the most severe instances need a consistent supply of nutrient-rich liquid. Mohammed’s baby is administered his nutrition through a syringe.

Suhayba Abdullah Abubakar’s baby boy, Sufian Sulaiman, is being fed through a nose tube. The baby has been sick for the past year but Abubakar was only provided with painkillers without any identification, until she made the trip from Alacha to Metche.

“Every day, I see additional kids arriving in this structure,” she says. “The meals we consume is inadequate, there’s insufficient food and it’s not nutritious.

“If we were at home, we could’ve adjusted our lives. You can go and grow crops, you can work to earn some money, but here we’re relying on what we’re distributed.”

And what they are provided is a limited quantity of cereal, vegetable oil and salt, distributed every two months. Such a basic diet lacks nutrition, and the small amount of money she is given acquires minimal items in the regular markets, where prices have become inflated.

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

Failing to secure jobs in Chad, her husband has gone to Libya in the desire to earning sufficient funds for them to come later. She stays with his relatives, dividing up whatever food they can get.

Abubakar says she has already seen food distributions being reduced and there are fears that the sharp decreases in international assistance funds by the US, UK and other European countries, could worsen the situation. Despite the war in Sudan having caused the 21st century’s gravest emergency and the {scale of needs|extent