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For hours, bouncing over the waterlogged dirt track to the medical facility, 18-year-old Makka Ibraheem Mohammed held on tight to her seat and concentrated on stopping herself throwing up. She was in childbirth, in extreme pain after her uterine wall split, but was now being tossed around in the ambulance that jumped along the dips and bumps 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 women. They stay in secluded encampments in the desert with scarce resources, few job opportunities and with treatment often a dangerously far away.

The hospital Mohammed needed was in Metche, a different settlement more than two hours away.

“I continuously experienced infections during my pregnancy and I had to go the medical tent seven times – when I was there, the delivery commenced. But I found it impossible to give birth naturally because my uterus had collapsed,” says Mohammed. “I had to endure a long delay for the ambulance but all I can think of the pain; it was so bad I became disoriented.”

Her parent, Ashe Khamis Abdullah, 40, worried she would be bereft of her child and grandchild. But Mohammed was rushed straight into surgery when she got to the hospital and an urgent C-section saved her and her son, Muwais.

Chad already had the world’s second worst maternal mortality rate before the current influx of refugees, but the circumstances suffered by the Sudanese place additional women in danger.

At the hospital, where they have assisted in the arrival of 824 babies in frequently urgent circumstances this year, the medical staff are able to save many, but it is what occurs with the women who are fail to get to the hospital that worries the staff.

In the 24 months since the domestic strife in Sudan erupted, over four-fifths of the refugees who have arrived and settled in Chad are mothers and kids. In total, about one point two million Sudanese are being hosted in the eastern region of the country, four hundred thousand of whom fled the previous conflict in Darfur.

Chad has hosted the bulk 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 adult men have stayed behind to be in proximity to homes and land; many were killed, abducted or conscripted. Those of employable age rapidly leave from Chad’s desolate refugee camps to find work in the main city, N’Djamena, or beyond, in adjacent Libya.

It results in women are abandoned, without the means to provide for the children and the elderly left in their care. To avoid overcrowding near the border, the Chadian government has transferred refugees to smaller camps such as Metche with average populations of about 50,000, but in remote areas with no services and minimal chances.

Metche has a hospital built by a medical aid organization, which started off as a few tents but has expanded to include an surgical room, but little else. There is a lack of jobs, families must walk hours to find firewood, and each person must get by with about a small amount of water a day – much less than the advised quantity.

This isolation means hospitals are receiving women with issues in their pregnancy dangerously late. There is only a sole emergency vehicle to serve the area between the Metche hospital and the medical tent near the camp at Alacha, where Mohammed is one of nearly 50,000 refugees. The medical team has seen cases where women in desperate pain have had to remain overnight for the ambulance to arrive.

Imagine being in the final trimester, in delivery, and travelling hours on a donkey-drawn vehicle to get to a medical facility

As well as being bumpy, the route passes through valleys that become inundated during the wet period, completely blocking travel.

A surgeon at the hospital in Metche said each patient she treats is an crisis, with some women having to make arduous trips to the hospital by on foot or on a donkey.

“Imagine being nine months pregnant, in childbirth, and making a long trip on a cart pulled by a donkey to get to a hospital. The primary issue is the lag but having to come in these conditions also has an influence on the delivery,” says the surgeon.

Undernourishment, which is increasing, also increases the risk of problems in pregnancy, including the uterine ruptures that medical staff frequently observe.

Mohammed has stayed at the medical facility in the two months since her C-section. Experiencing malnutrition, she got sick, while her son has been closely watched. The male guardian has travelled to other towns in seek jobs, so Mohammed is completely reliant on her mother.

The nutritional care section has grown to six tents and has cases exceeding capacity into other sections. Children lie under mosquito nets in sweltering heat in almost utter stillness as medical staff work, mixing medications and weighing children on a instrument created using a container and string.

In less severe situations children get sachets of PlumpyNut, the specially formulated peanut paste, but the most severe instances need a consistent supply of enriched milk. Mohammed’s baby is fed his through a injector.

Suhayba Abdullah Abubakar’s infant son, Sufian Sulaiman, is being fed through a nasal drip. The baby has been ill for the past year but Abubakar was consistently offered just painkillers without any medical assessment, until she made the journey from Alacha to Metche.

“Every day, I see additional kids coming in in this structure,” she says. “The meals we consume is low-quality, there’s not enough to eat and it’s not nutritious.

“If we were at home, we could’ve adjusted our lives. You can go and grow crops, you can work to earn some money, but here we’re dependent on what we’re given.”

And what they are given is a limited quantity of sorghum, vegetable oil and salt, handed out 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 local bazaars, where costs have risen.

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

Finding no work in Chad, her husband has traveled to Libya in the desire to raising enough money for them to join him. She stays with his kin, distributing whatever food they can get.

Abubakar says she has already seen food distributions being reduced and there are concerns that the sharp decreases in foreign support money by the US, UK and other European countries, could make things worse. Despite the war in Sudan having caused the 21st century’s worst humanitarian disaster and the {scale of needs|extent