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For a long time, travelling roughly on 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 childbirth, in severe suffering after her uterus ruptured, 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 close to a million Sudanese refugees who have fled to Chad since 2023, living hand to mouth in this difficult terrain, are females. They live in secluded encampments in the desert with insufficient supplies, little employment and with medical help often a life-threateningly long distance away.

The clinic Mohammed needed was in Metche, another refugee camp more than two hours away.

“I kept getting infections during my term and I had to go the medical tent seven times – when I was there, the pregnancy started. But I found it impossible to 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 suffering; it was so bad I became confused.”

Her mother, Ashe Khamis Abdullah, 40, was terrified she would lose both her child and grandchild. But Mohammed was hurried into surgery when she reached the hospital and an emergency caesarean section preserved the lives of her and her son, Muwais.

Chad was known for the world’s second most severe maternal fatality statistic before the current influx of refugees, but the conditions endured by the Sudanese expose further women in risk.

At the hospital, where they have delivered 824 babies in frequently urgent circumstances this year, the medical staff are able to help plenty, but it is what affects the women who are not able to reach the hospital that alarms the professionals.

In the 24 months since the internal conflict in Sudan started, the vast majority of the displaced persons who came and remained in Chad are women and children. In total, about over a million Sudanese are being hosted in the eastern region of the country, four hundred thousand of whom ran from the previous conflict in Darfur.

Chad has accepted the majority 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 uprooted from their homes.

Many adult men have remained to be close to homes and land; some were killed, abducted or conscripted. Those of adult age soon depart from Chad’s barren settlements to find work in the capital, N’Djamena, or beyond, in neighbouring Libya.

It means women are stranded, without the ability 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 fifty thousand, but in distant locations with few facilities and few opportunities.

Metche has a hospital established by a medical aid organization, which was initially a few tents but has expanded to include an procedure area, but not much more. There is no work, families must journey for extended periods to find fuel, and each person must get by with about a small amount of water a day – well under the recommended 20 litres.

This isolation means hospitals are treating women with complications in their pregnancy at a critical stage. There is only a one medical transport to serve the area between the Metche hospital and the health post near the Alacha encampment, where Mohammed is one of a large number of refugees. The medical team has encountered situations where women in extreme agony have had to wait an entire night for the ambulance to reach them.

Imagine being expecting a child, in childbirth, and travelling hours on a animal-drawn transport to get to a clinic

As well as being bumpy, the road traverses valleys that flood during the wet period, completely blocking travel.

A surgeon at the hospital in Metche said each patient she treats is an emergency, with some women having to make challenging travels to the hospital by on foot or on a pack animal.

“Imagine being in the late stages of pregnancy, in childbirth, and making a long trip on a cart pulled by a donkey to get to a clinic. The biggest factor is the lag but having to come in these conditions also has an effect on the birth,” says the surgeon.

Malnutrition, which is growing, also elevates the likelihood of complications in pregnancy, including the uterine ruptures that medical staff frequently observe.

Mohammed has stayed at the medical facility in the couple of months since her caesarean. Experiencing malnutrition, she got sick, while her son has been carefully monitored. The father has journeyed to other towns in look for employment, so Mohammed is completely reliant on her mother.

The malnutrition ward has grown to six tents and has cases exceeding capacity into other sections. Children rest beneath mosquito nets in extreme warmth in almost utter stillness as doctors and nurses work, preparing treatments and assessing weights on a device constructed from a container and string.

In mild cases children get small bags of PlumpyNut, the uniquely designed peanut paste, but the most severe instances need a daily dose of fortified formula. Mohammed’s baby is given his nourishment through a medical device.

Suhayba Abdullah Abubakar’s infant son, Sufian Sulaiman, is being given nutrition by a nasogastric tube. The infant has been sick 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 tent,” she says. “The nutrition we receive is poor, there’s insufficient food and it’s not nutritious.

“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 dependent on what we’re given.”

And what they are given is a meager portion of sorghum, edible oil and salt, handed out every 60 days. Such a basic diet is deficient in nutrients, and the small amount of money she is given acquires minimal items in the regular markets, where costs have risen.

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

Failing to secure jobs in Chad, her partner has gone to Libya in the desire to raising enough money for them to join him. She resides with his relatives, dividing up whatever nourishment they obtain.

Abubakar says she has already seen food supplies decreasing and there are worries that the abrupt cuts in international assistance funds by the US, UK and other European countries, could worsen the situation. Despite the war in Sudan having produced the 21st century’s most severe crisis and the {scale of needs|extent