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For a long time, bouncing over the flooded dirt track to the clinic, 18-year-old Makka Ibraheem Mohammed clung desperately to her seat and focused on stopping herself throwing up. She was in delivery, in agonizing discomfort after her uterus ruptured, but was now being jostled relentlessly in the ambulance that lurched across 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, surviving precariously in this harsh landscape, are women. They live in remote settlements in the desert with insufficient supplies, little employment and with medical help often a dangerously far away.

The medical center Mohammed needed was in Metche, a different settlement more than a considerable journey away.

“I continuously experienced infections during my term and I had to go the medical tent seven times – when I was there, the delivery commenced. But I wasn’t able to give birth normally because my uterine muscles failed,” says Mohammed. “I had to remain for 120 minutes for the ambulance but all I recall is the agony; it was so intense I became disoriented.”

Her parent, Ashe Khamis Abdullah, 40, feared she would suffer the death of her child and grandchild. But Mohammed was hurried into surgery when she arrived at the hospital and an critical surgical delivery rescued her and her son, Muwais.

Chad previously recorded the world’s second most severe maternal death rate before the ongoing stream of refugees, but the circumstances suffered by the Sudanese put even more women in risk.

At the hospital, where they have assisted in the arrival of 824 babies in often critical situations this year, the doctors are able to help plenty, but it is what affects the women who are cannot access the hospital that worries the staff.

In the two years since the civil war in Sudan began, the vast majority of the people who reached and settled in Chad are mothers and kids. In total, about over a million Sudanese are being accommodated in the east of the country, 400,000 of whom ran from the previous conflict in Darfur.

Chad has accepted the majority of the 4.1 million people who have fled the war in Sudan; others have gone to South Sudan, Egypt and Ethiopia. A total of 11.8 million Sudanese have been forced out of their homes.

Many men have stayed behind to be near homes and land; some were murdered, captured or conscripted. Those of adult age soon depart from Chad’s barren settlements to look for jobs in the main city, N’Djamena, or beyond, in neighbouring Libya.

It means women are stranded, without the ability to provide for the dependents left in their charge. To reduce density near the border, the Chadian government has transferred refugees to more compact settlements such as Metche with typical numbers of about 50,000, but in remote areas with few facilities and minimal chances.

Metche has a hospital established by a medical aid organization, which started off as a few tents but has developed to contain an surgical room, but little else. There is no work, families must walk hours to find firewood, and each person must subsist with about a small amount of water a day – much less than the recommended 20 litres.

This isolation means hospitals are admitting women with problems in their pregnancy at a critical stage. There is only a single ambulance 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 desperate pain have had to endure a full night for the ambulance to arrive.

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

As well as being rough, the route passes through valleys that fill with water during the monsoon, completely cutting off travel.

A surgeon at the hospital in Metche said each patient she treats 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 nine months pregnant, in childbirth, and journeying for an extended time on a donkey cart to get to a medical center. The main problem is the delay but having to arrive under such circumstances also has an influence on the delivery,” says the surgeon.

Poor nutrition, which is increasing, also elevates the likelihood of problems in pregnancy, including the uterine splits that medical staff see regularly.

Mohammed has continued under care in the couple of months since her surgical delivery. Suffering from malnutrition, she got sick, while her son has been carefully monitored. The male guardian has travelled to other towns in search of work, so Mohammed is entirely leaning on her mother.

The nutritional care section has increased to six tents and has patients spilling over into other sections. Children rest beneath mosquito nets in oppressive temperatures in almost total quiet as doctors and nurses work, preparing treatments and assessing weights on a instrument created using a pail and cord.

In moderate instances children get packets of PlumpyNut, the uniquely designed peanut paste, but the most severe instances need a consistent supply of nutrient-rich liquid. Mohammed’s baby is given his nourishment through a syringe.

Suhayba Abdullah Abubakar’s 11-month-old boy, Sufian Sulaiman, is being fed through a nasal drip. The child has been sick for the past year but Abubakar was only provided with painkillers without any identification, until she made the trip from Alacha to Metche.

“Every day, I see additional kids joining us in this tent,” she says. “The nutrition we receive is inadequate, there’s not enough to eat and it’s deficient in vitamins.

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

And what they are given is a meager portion of grain, vegetable oil and salt, handed out every 60 days. Such a basic diet offers little sustenance, and the meager funds she is given cannot buy much in the local bazaars, where costs have risen.

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

Finding no work in Chad, her partner has gone to Libya in the aspiration to gathering adequate cash for them to join him. She lives with his relatives, dividing up whatever food they can get.

Abubakar says she has already witnessed food distributions being reduced and there are worries that the sudden reductions 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 worst humanitarian disaster and the {scale of needs|extent