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For an extended period, jolting along the flooded dirt track to the medical facility, 18-year-old Makka Ibraheem Mohammed gripped firmly to her seat and tried hard stopping herself being sick. She was in childbirth, in severe suffering after her womb tore, but was now being tossed around in the ambulance that lurched across the potholes and ridges of the road through the Chadian desert.

Most of the close to a million Sudanese displaced persons who escaped to Chad since 2023, barely getting by in this difficult terrain, 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, one more encampment more than 120 minutes away.

“I continuously experienced infections during my gestation and I had to go the clinic on numerous visits – when I was there, the labour began. But I wasn’t able to give birth normally because my uterine muscles failed,” says Mohammed. “I had to wait two hours for the ambulance but all I can think of the agony; it was so intense I became delirious.”

Her maternal figure, Ashe Khamis Abdullah, 40, was terrified she would be bereft of her daughter and baby grandson. But Mohammed was rushed straight into surgery when she reached the hospital and an critical surgical delivery preserved the lives of her and her son, Muwais.

Chad was known for the world’s second worst maternal fatality statistic before the current influx of refugees, but the conditions endured by the Sudanese put even more women in peril.

At the hospital, where they have birthed 824 babies in mostly emergency conditions this year, the medics are able to rescue numerous, but it is what happens to the women who are not able to reach the hospital that alarms the professionals.

In the 24 months since the civil war in Sudan started, 86% of the people who reached and settled in Chad are females and minors. In total, about over a million Sudanese are being hosted in the east of the country, four hundred thousand of whom fled the previous conflict in Darfur.

Chad has taken the lion’s share of the over four million people who have escaped the war in Sudan; the remainder moved to South Sudan, Egypt and Ethiopia. A total of millions of Sudanese have been forced out of their homes.

Many men have stayed behind to be near homes and land; some were slain, abducted or conscripted. Those of employable age soon depart from Chad’s isolated encampments to find work in the main city, N’Djamena, or elsewhere, in nearby Libya.

It means women are stranded, without the means to provide for the children and the elderly left in their charge. To avoid overcrowding near the border, the Chadian government has transferred refugees to more compact settlements such as Metche with typical numbers of about a large community, but in remote areas with few facilities and scarce prospects.

Metche has a hospital set up by a medical aid organization, which was initially a few tents but has expanded to include an procedure area, but few additional amenities. There is a lack of jobs, families must journey for extended periods to find fuel, and each person must subsist with about a small amount of water a day – much less than the advised quantity.

This isolation means hospitals are admitting women with complications in their pregnancy dangerously late. There is only a single ambulance to travel the path between the Metche hospital and the medical tent near the Alacha encampment, where Mohammed is one of nearly 50,000 refugees. The medical team has encountered situations where women in severe suffering have had to endure a full night for the ambulance to come.

Imagine being in the final trimester, in childbirth, and making a lengthy trip on a donkey-drawn vehicle to get to a hospital

As well as being bumpy, the path goes through valleys that flood during the monsoon, 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 donkey.

“Imagine being in the late stages of pregnancy, in labour, and travelling hours on a animal-drawn vehicle to get to a clinic. The primary issue is the delay but having to arrive under such circumstances also has an influence on the delivery,” says the surgeon.

Poor nutrition, which is on the rise, also elevates the likelihood of complications in pregnancy, including the uterine splits that medical staff frequently observe.

Mohammed has remained in hospital in the couple of months since her caesarean. Suffering from malnutrition, she got sick, while her son has been regularly checked. The parent has travelled to other towns in seek jobs, so Mohammed is completely reliant on her mother.

The undernourishment unit has increased to six tents and has individuals overflowing into other sections. Children are placed under mosquito nets in oppressive temperatures in almost total quiet as health workers work, creating remedies and weighing children on a device constructed from a container and string.

In mild cases children get packets of PlumpyNut, the specially formulated peanut paste, but the critical situations need a daily dose of fortified formula. Mohammed’s baby is administered his nutrition through a injector.

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

“Every day, I see further minors coming in in this structure,” she says. “The food we’re eating 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 reliant on what we’re distributed.”

And what they are given is a meager portion of grain, vegetable oil and salt, provided every couple of months. Such a basic diet offers little sustenance, and the small amount of money she is given cannot buy much in the regular markets, where values have increased.

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

Finding no work in Chad, her husband has left for Libya in the desire to raising enough money for them to follow. She lives with his relatives, dividing up whatever food they can get.

Abubakar says she has already witnessed food supplies decreasing and there are concerns that the abrupt cuts in international assistance funds by the US, UK and other European countries, could deteriorate conditions. Despite the war in Sudan having created the 21st century’s worst humanitarian disaster and the {scale of needs|extent