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For a long time, jolting along the waterlogged dirt track to the hospital, 18-year-old Makka Ibraheem Mohammed clung desperately to her seat and focused on stopping herself vomiting. She was in labour, in severe suffering after her womb tore, but was now being jostled relentlessly in the ambulance that lurched across the dips and bumps of the road through the Chadian desert.

Most of the close to a million Sudanese people who ran to Chad since 2023, surviving precariously in this difficult terrain, are women. They reside in remote settlements in the desert with insufficient supplies, little employment and with treatment often a perilously remote away.

The clinic Mohammed needed was in Metche, a different settlement more than two hours away.

“I continuously experienced infections during my term and I had to go the clinic multiple occasions – 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 recall is the agony; it was so intense I became delirious.”

Her parent, Ashe Khamis Abdullah, 40, was terrified she would be bereft of her offspring and descendant. But Mohammed was rushed straight into surgery when she arrived at the hospital and an emergency caesarean section saved her and her son, Muwais.

Chad already had the world’s second most severe maternal mortality rate before the ongoing stream of refugees, but the circumstances suffered by the Sudanese put even more women in peril.

At the hospital, where they have delivered 824 babies in frequently urgent circumstances this year, the medics are able to help plenty, but it is what happens to the women who are fail to get to the hospital that worries the staff.

In the two years since the internal conflict in Sudan started, over four-fifths of the refugees who have arrived and settled 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 escaped the earlier war in Darfur.

Chad has hosted the bulk of the over four million people who have escaped the war in Sudan; others have gone to South Sudan, Egypt and Ethiopia. A total of almost twelve million Sudanese have been uprooted from their homes.

Many men have not left to be close to homes and land; many were murdered, captured or conscripted. Those of working age move on quickly from Chad’s isolated encampments to seek employment in the main city, N’Djamena, or elsewhere, in neighbouring Libya.

It means women are left alone, without the ability to provide for the dependents left in their care. To prevent congestion near the border, the Chadian government has moved individuals to less crowded encampments such as Metche with typical numbers of about a large community, but in distant locations with limited infrastructure and scarce prospects.

Metche has a hospital set up by a medical aid organization, which was initially a few tents but has developed to contain an surgical room, but not much more. There is no work, families must travel long distances to find fuel, and each person must get by with about a small amount of water a day – far below the suggested amount.

This isolation means hospitals are treating women with problems in their pregnancy dangerously late. There is only a single ambulance to travel the path between the Metche hospital and the clinic near the settlement of Alacha, 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 in the final trimester, in labour, and making a lengthy trip on a donkey-drawn vehicle to get to a hospital

As well as being rough, the route passes through valleys that flood during the monsoon, 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 walking 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 medical center. The main problem is the lag but having to arrive under such circumstances also has an impact on the childbirth,” says the surgeon.

Undernourishment, which is growing, also elevates the likelihood of complications in pregnancy, including the womb tears that medical staff often encounter.

Mohammed has stayed at the medical facility in the two months since her surgical delivery. Suffering from malnutrition, she developed an infection, while her son has been regularly checked. The male guardian has gone to other towns in seek jobs, so Mohammed is entirely leaning on her mother.

The undernourishment unit has increased to six tents and has patients spilling over into other sections. Children are placed under mosquito nets in sweltering heat in almost utter stillness as health workers work, preparing treatments and weighing children on a device constructed from a container and string.

In less severe situations children get packets of PlumpyNut, the specifically created peanut paste, but the worst cases need a consistent supply of nutrient-rich liquid. Mohammed’s baby is given his nourishment through a syringe.

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

“Every day, I see further minors coming in in this structure,” she says. “The meals we consume is low-quality, there’s insufficient food and it’s lacking in nutrients.

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

And what they are provided is a meager portion of grain, edible oil and salt, provided every two months. Such a simple food offers little sustenance, and the meager funds she is given cannot buy much in the local bazaars, where prices have become inflated.

Abubakar was transferred to Alacha after coming from Sudan in 2023, having run from the armed group Rapid Support Forces’ attack on her home city of El Geneina in June that year.

Finding no work in Chad, her husband has left for Libya in the hope of earning sufficient funds for them to follow. She lives with his relatives, sharing out whatever food they can get.

Abubakar says she has already seen food distributions being reduced and there are fears that the sudden reductions in foreign support money by the US, UK and other European countries, could make things worse. Despite the war in Sudan having caused the 21st century’s worst humanitarian disaster and the {scale of needs|extent