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For hours, travelling roughly on the soggy dirt track to the hospital, 18-year-old Makka Ibraheem Mohammed held on tight to her seat and tried hard stopping herself throwing up. She was in labour, in extreme pain after her womb tore, but was now being jostled relentlessly in the ambulance that lurched across the uneven terrain of the road through the Chadian desert.

Most of the 878,000 Sudanese refugees who have fled to Chad since 2023, living hand to mouth in this harsh landscape, are women. They live in secluded encampments in the desert with scarce resources, little employment and with medical help often a dangerously far away.

The clinic Mohammed needed was in Metche, a different settlement more than 120 minutes away.

“I kept getting infections during my term and I had to go the health post seven times – when I was there, the pregnancy started. 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 remember was the pain; it was so unbearable I became delirious.”

Her maternal figure, Ashe Khamis Abdullah, 40, feared she would lose both her offspring and descendant. But Mohammed was hurried into surgery when she got to the hospital and an emergency caesarean section saved her and her son, Muwais.

Chad already had the world’s second-highest maternal fatality statistic before the current influx of refugees, but the situations faced by the Sudanese put even more women in danger.

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 occurs with the women who are cannot access the hospital that worries the staff.

In the couple of years since the internal conflict in Sudan started, over four-fifths of the refugees who have arrived and remained in Chad are mothers and kids. In total, about 1.2 million Sudanese are being sheltered in the eastern part of the country, a large number of whom escaped the previous conflict in Darfur.

Chad has hosted the bulk of the millions of people who have run from the war in Sudan; some have travelled to South Sudan, Egypt and Ethiopia. A total of 11.8 million Sudanese have been forced out of their homes.

Many adult men have stayed behind to be close to homes and land; many were slain, abducted or forced into fighting. Those of working age soon depart from Chad’s desolate refugee camps to look for jobs in the main city, N’Djamena, or elsewhere, in neighbouring Libya.

It means women are stranded, without the ability to sustain the dependents left in their care. To prevent congestion near the border, the Chadian government has transferred refugees to less crowded encampments such as Metche with average populations of about a large community, but in remote areas with few facilities and scarce prospects.

Metche has a hospital established by a medical aid organization, which began as a few tents but has developed to contain an operating theatre, but few additional amenities. There is a lack of jobs, families must travel long distances to find firewood, and each person must get by with about minimal water of water a day – much less than the suggested amount.

This seclusion means hospitals are admitting women with complications in their pregnancy when it is almost too late. There is only a one medical transport to cover the route between the Metche hospital and the medical tent near the camp at Alacha, where Mohammed is one of close to fifty thousand refugees. The medical team has observed instances where women in desperate pain have had to wait an entire night for the ambulance to reach them.

Imagine being nine months pregnant, in childbirth, and making a lengthy trip on a animal-drawn transport to get to a medical facility

As well as being bumpy, the route passes through valleys that fill with water during the wet period, completely preventing travel.

A surgeon at the hospital in Metche said every case she sees is an critical situation, with some women having to make arduous trips to the hospital by foot or on a pack animal.

“Imagine being about to give birth, 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 come in these conditions also has an influence on the delivery,” says the surgeon.

Malnutrition, which is increasing, also elevates the likelihood of issues in pregnancy, including the womb tears that medical staff see regularly.

Mohammed has stayed at the medical facility in the two months since her surgical delivery. Experiencing malnutrition, she developed an infection, while her son has been closely watched. The male guardian has journeyed to other towns in search of work, so Mohammed is totally dependent on her mother.

The nutritional care section has expanded to six tents and has individuals overflowing into other sections. Children are placed under mosquito nets in extreme warmth in almost total quiet as doctors and nurses work, creating remedies and weighing children on a device constructed from a pail and cord.

In moderate instances children get packets of PlumpyNut, the specifically created peanut paste, but the critical situations need a daily dose of fortified formula. Mohammed’s baby is given his nourishment through a syringe.

Suhayba Abdullah Abubakar’s 11-month-old boy, Sufian Sulaiman, is being given nutrition by a nasogastric tube. The child has been ill for the past year but Abubakar was only provided with painkillers without any medical assessment, until she made the journey from Alacha to Metche.

“Every day, I see additional kids joining us in this shelter,” she says. “The meals we consume is poor, there’s too little nourishment and it’s lacking in nutrients.

“If we were at home, we could’ve adapted ourselves. You can go and cultivate plants, 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 couple of months. Such a simple food offers little sustenance, and the small amount of money she is given purchases very little in the regular markets, where prices have become inflated.

Abubakar was moved to Alacha after arriving from Sudan in 2023, having run from the armed group Rapid Support Forces’ assault on her native town of El Geneina in June that year.

Finding no work in Chad, her spouse has gone to Libya in the hope of earning sufficient funds for them to come later. She resides with his family members, dividing up whatever meals they acquire.

Abubakar says she has already observed food supplies decreasing and there are worries 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 worst humanitarian disaster and the {scale of needs|extent