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For a long time, bouncing over the soggy dirt track to the clinic, 18-year-old Makka Ibraheem Mohammed gripped firmly to her seat and concentrated on stopping herself being sick. She was in childbirth, in extreme pain 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 displaced persons who escaped to Chad since 2023, barely getting by in this harsh landscape, are women. They live in remote settlements in the desert with scarce resources, 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 continuously experienced infections during my pregnancy and I had to go the health post multiple occasions – when I was there, the delivery commenced. 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 recall is the agony; it was so bad I became delirious.”

Her parent, Ashe Khamis Abdullah, 40, feared she would suffer the death of her daughter and baby grandson. But Mohammed was rushed straight into surgery when she reached the hospital and an emergency caesarean section rescued her and her son, Muwais.

Chad was known for the world’s second most severe maternal death rate before the recent arrival of refugees, but the situations faced by the Sudanese place additional women in peril.

At the hospital, where they have birthed 824 babies in often critical situations this year, the medics are able to rescue numerous, but it is what happens to the women who are not able to reach the hospital that concerns them.

In the two years since the civil war in Sudan erupted, over four-fifths of the refugees who have arrived and stayed in Chad are females and minors. In total, about over a million Sudanese are being accommodated in the eastern part 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 run from 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 remained to be in proximity to homes and land; many were slain, captured or made to join the conflict. Those of employable age rapidly leave from Chad’s desolate refugee camps to look for jobs in the main city, N’Djamena, or beyond, in adjacent Libya.

It results in women are left alone, without the means to sustain the dependents left in their charge. To prevent congestion near the border, the Chadian government has relocated people to smaller camps such as Metche with typical numbers of about 50,000, but in remote areas with limited infrastructure and few opportunities.

Metche has a hospital set up by a medical aid organization, which began as a few tents but has grown to feature an surgical room, but not much more. There is no work, families must travel long distances to find burning material, and each person must subsist with about minimal water of water a day – far below the advised quantity.

This isolation means hospitals are receiving women with complications in their pregnancy dangerously late. There is only a single ambulance to serve the area between the Metche hospital and the clinic near the camp at Alacha, 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 come.

Imagine being expecting a child, in labour, and making a lengthy trip on a animal-drawn transport to get to a hospital

As well as being rough, the route passes through valleys that fill with water during the wet period, completely blocking travel.

A surgeon at the hospital in Metche said every case she sees is an crisis, with some women having to make long and difficult journeys to the hospital by walking or on a pack animal.

“Imagine being in the late stages of pregnancy, in delivery, and travelling hours on a animal-drawn vehicle to get to a hospital. The main problem is the wait but having to arrive under such circumstances also has an influence on the childbirth,” says the surgeon.

Poor nutrition, which is increasing, also raises the chance of complications in pregnancy, including the uterine ruptures that medical staff see regularly.

Mohammed has remained in hospital in the 60 days since her C-section. Experiencing malnutrition, she got sick, while her son has been carefully monitored. The parent has gone to other towns in look for employment, so Mohammed is completely reliant on her mother.

The undernourishment unit has expanded to six tents and has individuals overflowing into other sections. Children rest beneath mosquito nets in extreme warmth in almost total quiet as medical staff work, preparing treatments and weighing children on a scale made from a pail and cord.

In less severe situations children get sachets of PlumpyNut, the uniquely designed peanut paste, but the most severe instances need a regular intake of enriched milk. Mohammed’s baby is fed his through a syringe.

Suhayba Abdullah Abubakar’s 11-month-old boy, Sufian Sulaiman, is being given nutrition by a nasogastric tube. The baby has been unwell for the past year but Abubakar was only provided with painkillers without any medical assessment, until she made the travel from Alacha to Metche.

“Every day, I see further minors coming in in this structure,” she says. “The meals we consume is low-quality, there’s too little nourishment and it’s not nutritious.

“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 relying on what we’re given.”

And what they are allocated is a meager portion of cereal, vegetable oil and salt, provided every couple of months. Such a simple food lacks nutrition, and the small amount of money she is given acquires minimal items in the weekly food markets, where costs have risen.

Abubakar was transferred to Alacha after reaching from Sudan in 2023, having run from the armed group 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 aspiration to gathering adequate cash for them to join him. She stays with his family members, sharing out whatever meals they acquire.

Abubakar says she has already observed food rations being cut and there are fears 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 produced the 21st century’s most severe crisis and the {scale of needs|extent