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For a long time, travelling roughly on the flooded dirt track to the clinic, 18-year-old Makka Ibraheem Mohammed gripped firmly to her seat and focused on stopping herself being sick. She was in labour, in agonizing discomfort after her uterine wall split, but was now being tossed around in the ambulance that lurched across the potholes and ridges of the road through the Chadian desert.

Most of the hundreds of thousands of Sudanese displaced persons who escaped to Chad since 2023, surviving precariously in this harsh landscape, are females. They live in isolated camps in the desert with limited water and food, few job opportunities and with healthcare often a life-threateningly long distance away.

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

“I kept getting infections during my pregnancy and I had to go the health post on numerous visits – when I was there, the delivery commenced. But I wasn’t able to give birth without intervention because my womb had given way,” says Mohammed. “I had to remain for 120 minutes for the ambulance but all I recall is the agony; it was so unbearable I became confused.”

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

Chad already had the world’s second worst maternal mortality rate before the recent arrival of refugees, but the circumstances suffered by the Sudanese put even more women in danger.

At the hospital, where they have birthed 824 babies in frequently urgent circumstances this year, the medics are able to rescue numerous, but it is what affects the women who are not able to reach the hospital that concerns them.

In the couple of years since the internal conflict in Sudan started, 86% of the people who reached and remained in Chad are females and minors. In total, about 1.2 million Sudanese are being hosted in the east of the country, a large number of whom escaped the earlier war in Darfur.

Chad has taken the lion’s share of the 4.1 million people who have escaped the war in Sudan; others have gone to South Sudan, Egypt and Ethiopia. A total of 11.8 million Sudanese have been uprooted from their homes.

Many men have not left to be in proximity to homes and land; many were murdered, captured or conscripted. Those of employable age rapidly leave from Chad’s isolated encampments to seek employment in the main city, N’Djamena, or beyond, in nearby Libya.

It results in women are stranded, without the resources to sustain the dependents left in their care. To prevent congestion near the border, the Chadian government has moved individuals to smaller camps such as Metche with average populations of about fifty thousand, but in isolated regions with no services and few opportunities.

Metche has a hospital built by a medical aid organization, which was initially a few tents but has developed to contain an operating theatre, but few additional amenities. There is unemployment, families must journey for extended periods to find fuel, and each person must subsist with about nine litres of water a day – much less than the suggested amount.

This isolation means hospitals are admitting women with issues in their pregnancy dangerously 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 encountered situations where women in extreme agony have had to remain overnight for the ambulance to reach them.

Imagine being nine months pregnant, in labour, and making a lengthy trip on a animal-drawn transport to get to a hospital

As well as being uneven, the path goes through valleys that flood during the rainy season, completely preventing 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 mule.

“Imagine being nine months pregnant, in labour, and travelling hours on a donkey cart to get to a medical center. The biggest factor is the delay but having to come in these conditions also has an effect on the delivery,” says the surgeon.

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

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

The undernourishment unit has increased to six tents and has patients spilling over into other sections. Children lie under mosquito nets in oppressive temperatures in almost total quiet as medical staff work, creating remedies and assessing weights on a device constructed from a container and string.

In moderate instances children get sachets of PlumpyNut, the specifically created peanut paste, but the most severe instances need a daily dose of fortified formula. Mohammed’s baby is administered his nutrition through a syringe.

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

“Every day, I see more children joining us in this shelter,” she says. “The nutrition we receive is inadequate, there’s too little nourishment 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 work to earn some money, but here we’re dependent on what we’re given.”

And what they are allocated is a limited quantity of grain, edible oil and salt, provided every 60 days. Such a basic diet is deficient in nutrients, and the meager funds she is given acquires minimal items in the weekly food markets, where costs have risen.

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

Failing to secure jobs in Chad, her spouse has gone to Libya in the aspiration to gathering adequate cash for them to come later. She resides with his kin, dividing up whatever meals they acquire.

Abubakar says she has already witnessed food rations being cut and there are worries that the abrupt cuts in overseas aid budgets 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