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For a long time, bouncing over the soggy dirt track to the hospital, 18-year-old Makka Ibraheem Mohammed gripped firmly to her seat and focused on stopping herself being sick. She was in childbirth, in extreme pain after her womb tore, but was now being tossed around in the ambulance that bumped over the dips and bumps of the road through the Chadian desert.

Most of the 878,000 Sudanese displaced persons who escaped to Chad since 2023, living hand to mouth in this harsh landscape, are women. They live in remote settlements in the desert with scarce resources, no work and with healthcare often a dangerously far away.

The clinic Mohammed needed was in Metche, a different settlement 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 delivery commenced. But I wasn’t able to give birth naturally because my womb had given way,” says Mohammed. “I had to remain for 120 minutes for the ambulance but all I recall is the suffering; 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 arrived at the hospital and an emergency caesarean section rescued her and her son, Muwais.

Chad was known for the world’s second-highest maternal death rate before the recent arrival of refugees, but the conditions endured by the Sudanese expose further women in danger.

At the hospital, where they have delivered 824 babies in often critical situations this year, the medical staff are able to save many, but it is what occurs with the women who are not able to reach the hospital that worries the staff.

In the two years since the domestic strife in Sudan started, the vast majority of the displaced persons who came and remained in Chad are females and minors. In total, about over a million Sudanese are being accommodated in the east of the country, four hundred thousand of whom fled the previous conflict in Darfur.

Chad has accepted the majority of the 4.1 million people who have run from the war in Sudan; others have gone to South Sudan, Egypt and Ethiopia. A total of millions of Sudanese have been displaced from their homes.

Many men have not left to be in proximity to homes and land; some were killed, captured or conscripted. Those of employable age rapidly leave from Chad’s isolated encampments to find work in the capital, N’Djamena, or further, in nearby Libya.

It implies women are abandoned, without the ability to sustain the dependents left in their charge. To avoid overcrowding near the border, the Chadian government has relocated people to more compact settlements such as Metche with typical numbers of about a large community, but in distant locations with no services and few opportunities.

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 no work, families must journey for extended periods to find firewood, and each person must subsist with about a small amount of water a day – well under the advised quantity.

This remoteness means hospitals are treating women with issues in their pregnancy at a critical stage. There is only a sole emergency vehicle to travel the path 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 severe suffering have had to wait an entire night for the ambulance to come.

Imagine being in the final trimester, in labour, and making a lengthy trip on a animal-drawn transport to get to a clinic

As well as being bumpy, the road traverses valleys that become inundated during the wet period, completely cutting off travel.

A surgeon at the hospital in Metche said all the situations she encounters is an crisis, with some women having to make arduous trips to the hospital by foot or on a mule.

“Imagine being nine months pregnant, in childbirth, and journeying for an extended time on a animal-drawn vehicle to get to a hospital. The biggest factor is the wait but having to arrive under such circumstances also has an effect on the delivery,” says the surgeon.

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

Mohammed has stayed at the medical facility in the two months since her caesarean. Suffering from malnutrition, she developed an infection, while her son has been carefully monitored. The father has travelled to other towns in seek jobs, so Mohammed is completely reliant on her mother.

The undernourishment unit has grown to six tents and has individuals overflowing into other sections. Children rest beneath mosquito nets in extreme warmth in almost total quiet as doctors and nurses work, preparing treatments and assessing weights on a device constructed from a pail and cord.

In mild cases children get small bags of PlumpyNut, the specially formulated peanut paste, but the critical situations need a consistent supply of enriched milk. Mohammed’s baby is given his nourishment through a medical device.

Suhayba Abdullah Abubakar’s infant son, Sufian Sulaiman, is being fed through a nose tube. The child has been sick for the past year but Abubakar was repeatedly given only painkillers without any identification, until she made the trip from Alacha to Metche.

“Every day, I see additional kids coming in in this structure,” she says. “The nutrition we receive is inadequate, there’s too little nourishment and it’s not nutritious.

“If we were at home, we could’ve adapted ourselves. You can go and farm produce, you can work to earn some money, but here we’re dependent on what we’re provided.”

And what they are given is a small amount of grain, edible oil and salt, distributed every two months. Such a minimal nutrition lacks nutrition, and the little cash she is given acquires minimal items in the local bazaars, where prices have become inflated.

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

Unable to get employment in Chad, her spouse has gone to Libya in the desire to raising enough money for them to come later. She resides with his relatives, dividing up whatever food they can get.

Abubakar says she has already seen food rations being cut and there are worries that the sudden reductions in overseas aid budgets by the US, UK and other European countries, could make things worse. Despite the war in Sudan having created the 21st century’s worst humanitarian disaster and the {scale of needs|extent