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For an extended period, bouncing over the flooded dirt track to the medical facility, 18-year-old Makka Ibraheem Mohammed held on tight to her seat and focused on stopping herself vomiting. She was in childbirth, in severe suffering after her uterus ruptured, but was now being jostled relentlessly 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 people who ran to Chad since 2023, surviving precariously in this harsh landscape, are females. They live in remote settlements in the desert with insufficient supplies, little employment and with treatment often a dangerously far away.

The hospital Mohammed needed was in Metche, one more encampment more than a considerable journey away.

“I repeatedly suffered from infections during my pregnancy and I had to go the clinic seven times – when I was there, the labour began. But I could not give birth naturally because my womb had given way,” says Mohammed. “I had to endure a long delay for the ambulance but all I remember was the agony; it was so bad I became confused.”

Her maternal figure, Ashe Khamis Abdullah, 40, worried she would be bereft of her child and grandchild. But Mohammed was rushed straight 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 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 delivered 824 babies in frequently urgent circumstances this year, the medical staff are able to help plenty, but it is what occurs with the women who are fail to get to the hospital that concerns them.

In the 24 months since the civil war in Sudan erupted, over four-fifths of the people who reached and settled in Chad are females and minors. In total, about over a million Sudanese are being sheltered in the eastern part of the country, four hundred thousand of whom escaped the previous conflict in Darfur.

Chad has accepted the majority of the millions of people who have escaped 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 not left to be close to homes and land; some were murdered, taken hostage or conscripted. Those of employable age move on quickly from Chad’s isolated encampments to find work in the main city, N’Djamena, or elsewhere, in adjacent Libya.

It means women are stranded, without the means to provide for the dependents left in their responsibility. To reduce density near the border, the Chadian government has moved individuals to more compact settlements such as Metche with average populations of about 50,000, but in remote areas with no services and minimal chances.

Metche has a hospital set up by a medical aid organization, which began as a few tents but has developed to contain an operating theatre, but little else. There is a lack of jobs, families must journey for extended periods to find fuel, and each person must survive on about minimal water of water a day – much less than the recommended 20 litres.

This remoteness means hospitals are treating women with problems in their pregnancy when it is almost too late. There is only a sole emergency vehicle to travel the path between the Metche hospital and the health post near the camp at Alacha, where Mohammed is one of close to fifty thousand 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 nine months pregnant, in labour, and making a lengthy trip on a cart pulled by a donkey to get to a hospital

As well as being bumpy, the road traverses valleys that become inundated during the monsoon, completely blocking travel.

A surgeon at the hospital in Metche said all the situations she encounters is an crisis, with some women having to make long and difficult journeys to the hospital by foot or on a pack animal.

“Imagine being in the late stages of pregnancy, in delivery, and journeying for an extended time on a cart pulled by a donkey to get to a clinic. The main problem is the lag but having to arrive under such circumstances also has an impact on the delivery,” says the surgeon.

Malnutrition, which is on the rise, also raises the chance of complications in pregnancy, including the uterine ruptures that medical staff see regularly.

Mohammed has stayed at the medical facility in the two months since her surgical delivery. Suffering from malnutrition, she got sick, while her son has been carefully monitored. The male guardian has journeyed to other towns in look for employment, so Mohammed is totally dependent on her mother.

The malnutrition ward has expanded to six tents and has cases exceeding capacity into other sections. Children rest beneath mosquito nets in sweltering heat in almost complete silence as doctors and nurses work, preparing treatments and assessing weights on a instrument created using a bucket and rope.

In moderate instances children get small bags of PlumpyNut, the specifically created peanut paste, but the critical situations need a regular intake of nutrient-rich liquid. Mohammed’s baby is fed his through a injector.

Suhayba Abdullah Abubakar’s 11-month-old boy, Sufian Sulaiman, is being given nutrition by a nasogastric tube. The baby has been ill for the past year but Abubakar was consistently offered just painkillers without any identification, until she made the trip from Alacha to Metche.

“Every day, I see more children arriving in this shelter,” she says. “The meals we consume is inadequate, there’s insufficient food and it’s lacking in nutrients.

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

And what they are given is a small amount of sorghum, vegetable oil and salt, distributed every two months. Such a basic diet is deficient in nutrients, and the meager funds she is given acquires minimal items in the regular markets, where costs have risen.

Abubakar was relocated to Alacha after arriving from Sudan in 2023, having escaped the militia Rapid Support Forces’ attack on her home city of El Geneina in June that year.

Unable to get employment in Chad, her partner has traveled to Libya in the aspiration to raising enough money for them to come later. She lives with his relatives, sharing out whatever food they can get.

Abubakar says she has already observed food distributions being reduced and there are worries that the abrupt cuts in overseas aid budgets by the US, UK and other European countries, could deteriorate conditions. Despite the war in Sudan having caused the 21st century’s gravest emergency and the {scale of needs|extent