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For an extended period, bouncing over the waterlogged dirt track to the hospital, 18-year-old Makka Ibraheem Mohammed clung desperately to her seat and tried hard stopping herself being sick. She was in childbirth, in agonizing discomfort after her uterine wall split, but was now being shaken violently in the ambulance that jumped along 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 difficult terrain, are women. They stay in remote settlements in the desert with insufficient supplies, little employment and with healthcare 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 health post multiple occasions – when I was there, the pregnancy started. But I found it impossible to give birth normally because my uterus had collapsed,” says Mohammed. “I had to remain for 120 minutes for the ambulance but all I remember was the agony; it was so unbearable I became delirious.”

Her parent, Ashe Khamis Abdullah, 40, was terrified she would be bereft of her daughter and baby grandson. But Mohammed was hurried into surgery when she reached the hospital and an critical surgical delivery preserved the lives of her and her son, Muwais.

Chad was known for the world’s second worst maternal mortality rate before the ongoing stream of refugees, but the conditions endured by the Sudanese expose further women in peril.

At the hospital, where they have delivered 824 babies in mostly emergency conditions this year, the medics are able to help plenty, but it is what occurs with the women who are fail to get to the hospital that alarms the professionals.

In the two years since the civil war in Sudan erupted, over four-fifths of the people who reached and stayed in Chad are mothers and kids. In total, about over a million Sudanese are being hosted in the east of the country, 400,000 of whom escaped the past violence in Darfur.

Chad has taken the lion’s share of the over four million people who have run from the war in Sudan; the remainder moved to South Sudan, Egypt and Ethiopia. A total of millions of Sudanese have been displaced from their homes.

Many adult men have remained to be in proximity to homes and land; others have been murdered, abducted or forced into fighting. Those of working age move on quickly from Chad’s desolate refugee camps to find work in the capital, N’Djamena, or beyond, in neighbouring Libya.

It implies women are stranded, without the means to sustain the young and old left in their care. To prevent congestion near the border, the Chadian government has moved individuals to less crowded encampments such as Metche with usual resident counts of about fifty thousand, but in remote areas with limited infrastructure and scarce prospects.

Metche has a hospital set up by a medical aid organization, which was initially a few tents but has expanded to include an surgical room, but few additional amenities. There is a lack of jobs, families must journey for extended periods to find burning material, and each person must subsist with about a small amount of water a day – well under the recommended 20 litres.

This seclusion means hospitals are treating women with issues in their pregnancy when it is almost too late. There is only a one medical transport to cover the route between the Metche hospital and the clinic near the Alacha encampment, where Mohammed is one of nearly 50,000 refugees. The medical team has observed instances where women in extreme agony have had to endure a full night for the ambulance to reach them.

Imagine being expecting a child, in labour, and travelling hours on a donkey-drawn vehicle to get to a hospital

As well as being bumpy, the path goes through valleys that become inundated during the rainy season, completely cutting off travel.

A surgeon at the hospital in Metche said all the situations she encounters is an critical situation, with some women having to make long and difficult journeys to the hospital by walking or on a mule.

“Imagine being about to give birth, in childbirth, and travelling hours on a animal-drawn vehicle to get to a hospital. The primary issue is the lag but having to arrive under such circumstances also has an influence on the birth,” says the surgeon.

Undernourishment, which is increasing, also raises the chance of issues in pregnancy, including the uterine splits that medical staff frequently observe.

Mohammed has remained in hospital in the couple of months since her surgical delivery. Experiencing malnutrition, she developed an infection, while her son has been regularly checked. The parent has gone to other towns in seek jobs, so Mohammed is entirely leaning on her mother.

The undernourishment unit has increased to six tents and has cases exceeding capacity into other sections. Children lie under mosquito nets in oppressive temperatures in almost utter stillness as medical staff work, preparing treatments and assessing weights on a instrument created using a container and string.

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

Suhayba Abdullah Abubakar’s baby boy, Sufian Sulaiman, is being nourished via a nasogastric tube. The baby has been unwell for the past year but Abubakar was consistently offered just painkillers without any identification, until she made the journey from Alacha to Metche.

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

“If we were at home, we could’ve adapted ourselves. You can go and grow crops, you can get a job, but here we’re relying on what we’re given.”

And what they are provided is a small amount of sorghum, edible oil and salt, distributed every couple of months. Such a simple food lacks nutrition, and the meager funds she is given cannot buy much in the weekly food markets, where costs have risen.

Abubakar was moved to Alacha after arriving from Sudan in 2023, having run from the paramilitary Rapid Support Forces’ attack 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 hope of earning sufficient funds for them to follow. She stays with his family members, distributing whatever meals they acquire.

Abubakar says she has already seen food distributions being reduced and there are worries that the sudden reductions in international assistance funds by the US, UK and other European countries, could worsen the situation. Despite the war in Sudan having created the 21st century’s worst humanitarian disaster and the {scale of needs|extent