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For hours, travelling roughly on the soggy dirt track to the hospital, 18-year-old Makka Ibraheem Mohammed clung desperately to her seat and focused on stopping herself throwing up. She was in childbirth, in severe suffering after her uterine wall split, but was now being jostled relentlessly in the ambulance that jumped along the dips and bumps of the road through the Chadian desert.

Most of the close to a million Sudanese refugees who have fled to Chad since 2023, living hand to mouth in this harsh landscape, are females. They reside in remote settlements in the desert with scarce resources, few job opportunities and with healthcare often a life-threateningly long distance away.

The medical center 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 medical tent on numerous visits – when I was there, the delivery commenced. But I wasn’t able to give birth naturally because my womb had given way,” says Mohammed. “I had to remain for 120 minutes for the ambulance but all I can think of the suffering; it was so intense I became delirious.”

Her parent, Ashe Khamis Abdullah, 40, feared she would be bereft of her daughter and baby grandson. But Mohammed was immediately taken for surgery when she reached the hospital and an urgent C-section preserved the lives of her and her son, Muwais.

Chad was known for the world’s second-highest maternal mortality rate before the current influx of refugees, but the circumstances suffered by the Sudanese put even more women in danger.

At the hospital, where they have assisted in the arrival of 824 babies in often critical situations this year, the doctors are able to help plenty, but it is what happens to the women who are fail to get to the hospital that concerns them.

In the 24 months since the domestic strife in Sudan began, the vast majority of the displaced persons who came and remained in Chad are mothers and kids. In total, about over a million Sudanese are being hosted in the eastern region of the country, a large number of whom escaped the earlier war in Darfur.

Chad has accepted the majority of the millions of 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 adult men have not left to be in proximity to homes and land; some were slain, captured or conscripted. Those of working age soon depart from Chad’s barren settlements to find work in the main city, N’Djamena, or beyond, in neighbouring Libya.

It results in women are stranded, without the ability to feed the young and old left in their care. To reduce density near the border, the Chadian government has moved individuals to more compact settlements such as Metche with typical numbers 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 developed to contain an procedure area, but little else. There is unemployment, families must walk hours to find firewood, and each person must subsist with about minimal water of water a day – much less than the suggested amount.

This isolation means hospitals are treating women with issues in their pregnancy at a critical stage. There is only a one medical transport to travel the path between the Metche hospital and the health post near the camp at Alacha, where Mohammed is one of a large number of refugees. The medical team has seen cases where women in severe suffering have had to endure a full night for the ambulance to arrive.

Imagine being in the final trimester, in delivery, and making a lengthy trip on a cart pulled by a donkey to get to a hospital

As well as being bumpy, the route passes through valleys that flood during the rainy season, completely cutting off travel.

A surgeon at the hospital in Metche said each patient she treats is an critical situation, with some women having to make arduous trips to the hospital by walking or on a pack animal.

“Imagine being in the late stages of pregnancy, in childbirth, and making a long trip on a animal-drawn vehicle to get to a hospital. The biggest factor is the delay but having to arrive under such circumstances also has an effect on the childbirth,” says the surgeon.

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

Mohammed has stayed at the medical facility in the 60 days since her caesarean. Suffering from malnutrition, she contracted an illness, while her son has been carefully monitored. The father has travelled to other towns in search of work, so Mohammed is completely reliant on her mother.

The nutritional care section has expanded to six tents and has cases exceeding capacity into other sections. Children lie under mosquito nets in extreme warmth in almost complete silence as health workers work, creating remedies and assessing weights on a scale made from a pail and cord.

In moderate instances children get packets of PlumpyNut, the specially formulated peanut paste, but the critical situations need a consistent supply of enriched milk. Mohammed’s baby is given his nourishment through a syringe.

Suhayba Abdullah Abubakar’s infant son, Sufian Sulaiman, is being fed through a nose tube. The baby has been ill for the past year but Abubakar was consistently offered just painkillers without any identification, until she made the travel from Alacha to Metche.

“Every day, I see additional kids joining us in this shelter,” she says. “The nutrition we receive is inadequate, there’s not enough to eat and it’s lacking in nutrients.

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

And what they are given is a limited quantity of cereal, edible oil and salt, provided every 60 days. Such a simple food is deficient in nutrients, and the little cash she is given cannot buy much in the local bazaars, where values have increased.

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

Finding no work in Chad, her partner has traveled to Libya in the hope of earning sufficient funds for them to join him. She resides with his family members, sharing out whatever meals they acquire.

Abubakar says she has already witnessed food rations being cut and there are fears that the abrupt cuts in foreign support money by the US, UK and other European countries, could make things worse. Despite the war in Sudan having produced the 21st century’s most severe crisis and the {scale of needs|extent