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For a long time, jolting along the flooded dirt track to the clinic, 18-year-old Makka Ibraheem Mohammed gripped firmly to her seat and focused on stopping herself being sick. She was in labour, in severe suffering after her uterine wall split, but was now being shaken violently in the ambulance that lurched across the uneven terrain of the road through the Chadian desert.

Most of the close to a million Sudanese people who ran to Chad since 2023, living hand to mouth in this inhospitable environment, are females. They live in secluded encampments in the desert with insufficient supplies, 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 repeatedly suffered from infections during my pregnancy and I had to go the medical tent multiple occasions – when I was there, the labour began. But I found it impossible to give birth without intervention because my uterine muscles failed,” says Mohammed. “I had to wait two hours for the ambulance but all I recall is the suffering; it was so unbearable I became delirious.”

Her mother, Ashe Khamis Abdullah, 40, worried she would suffer the death of her daughter and baby grandson. But Mohammed was immediately taken for 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 worst maternal mortality rate before the ongoing stream of refugees, but the situations faced by the Sudanese place additional women in peril.

At the hospital, where they have delivered 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 cannot access the hospital that worries the staff.

In the couple of years since the internal conflict in Sudan erupted, the vast majority of the displaced persons who came and remained 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 past violence in Darfur.

Chad has accepted the majority of the millions of people who have fled the war in Sudan; the remainder moved to South Sudan, Egypt and Ethiopia. A total of 11.8 million Sudanese have been forced out of their homes.

Many men have stayed behind to be close to homes and land; some were murdered, abducted or conscripted. Those of working age soon depart from Chad’s desolate refugee camps to look for jobs in the main city, N’Djamena, or further, in adjacent Libya.

It means women are abandoned, without the ability to sustain the children and the elderly 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 no services and scarce prospects.

Metche has a hospital established by a medical aid organization, which was initially a few tents but has grown to feature an surgical room, but not much more. There is no work, families must walk hours to find firewood, and each person must survive on about nine litres of water a day – well under the advised quantity.

This isolation means hospitals are admitting 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 medical tent near the settlement of Alacha, where Mohammed is one of a large number of refugees. The medical team has encountered situations where women in desperate pain have had to endure a full night for the ambulance to come.

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 uneven, the route passes through valleys that fill with water during the rainy season, completely preventing 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 on foot or on a donkey.

“Imagine being in the late stages of pregnancy, in childbirth, and travelling hours on a donkey cart to get to a medical center. The primary issue 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 problems in pregnancy, including the womb tears that medical staff often encounter.

Mohammed has continued under care in the two months since her caesarean. Suffering from malnutrition, she developed an infection, while her son has been closely watched. The parent has travelled to other towns in look for employment, so Mohammed is completely reliant on her mother.

The undernourishment unit has increased to six tents and has cases exceeding capacity into other sections. Children are placed under mosquito nets in extreme warmth in almost utter stillness as health workers work, mixing medications and assessing weights on a scale made from a bucket and rope.

In mild cases children get sachets of PlumpyNut, the uniquely designed peanut paste, but the critical situations need a consistent supply of enriched milk. Mohammed’s baby is fed his through a medical device.

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

“Every day, I see further minors arriving in this tent,” she says. “The nutrition we receive is inadequate, there’s too little nourishment and it’s deficient in vitamins.

“If we were at home, we could’ve adapted ourselves. You can go and farm produce, you can find employment, but here we’re dependent on what we’re given.”

And what they are allocated is a small amount of grain, vegetable oil and salt, provided every two months. Such a basic diet lacks nutrition, and the little cash she is given purchases very little in the local bazaars, where costs have risen.

Abubakar was moved to Alacha after arriving from Sudan in 2023, having escaped the paramilitary Rapid Support Forces’ assault on her birthplace of El Geneina in June that year.

Unable to get employment in Chad, her husband has gone to Libya in the desire to gathering adequate cash for them to come later. She stays with his kin, distributing whatever food they can get.

Abubakar says she has already seen food rations being cut and there are fears that the sudden reductions in overseas aid budgets by the US, UK and other European countries, could deteriorate conditions. Despite the war in Sudan having produced the 21st century’s most severe crisis and the {scale of needs|extent