As the war in Sudan pushes more people across the border, malnutrition is on the rise in Chad's remote settlements where 86% of the refugees are women and children.
For hours, jolting along the waterlogged dirt track to the hospital, 18-year-old Makka Ibraheem Mohammed held on tight to her seat and focused on stopping herself vomiting. She was in labour, in extreme pain after her uterus ruptured, but was now being tossed around in the ambulance that jumped along the dips and bumps of the road through the Chadian desert.
Most of the 878,000 Sudanese refugees who have fled to Chad since 2023, living hand to mouth in this harsh landscape, are women. They stay in isolated camps in the desert with limited water and food, no work and with medical help often a life-threateningly long distance away.
The hospital Mohammed needed, run by the aid agency Médecins Sans Frontières (MSF), was in Metche, another refugee camp more than two hours away.
"I kept getting infections during my pregnancy and I had to go the clinic seven times - when I was there, the pregnancy started. But I wasn't able to give birth normally because my uterus had collapsed," says Mohammed. "I had to wait two hours for the ambulance but all I remember was the pain; it was so bad I became delirious."
Her mother, Ashe Khamis Abdullah, 40, feared she would lose both her daughter and baby grandson. But Mohammed was rushed straight into surgery when she arrived at the hospital and an emergency caesarean section saved her and her son, Muwais.
Chad already had the world's second-highest maternal mortality rate before the current influx of refugees, but the conditions endured by the Sudanese put even more women in danger.
At the MSF hospital, where they have delivered 824 babies in mostly emergency conditions this year, the medics are able to save many, 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 began, 86% of the refugees who have arrived and remained in Chad are women and children. In total, about 1.2 million Sudanese are being hosted in the eastern part of the country, 400,000 of whom fled the previous conflict 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 displaced from their homes.
Many men have stayed behind to be close to homes and land; others have been killed, taken hostage 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 further, in neighbouring Libya.
it means women are left alone, without the means to feed the children and the elderly left in their care. To avoid overcrowding near the border, the Chadian government has relocated people to smaller camps such as Metche with average populations of about 50,000, but in remote areas with no services and few opportunities.
Metche has a hospital built by MSF, which started off as a few tents but has expanded to include an operating theatre, but little else. There is no work, families must walk hours to find firewood, and each person must survive on about nine litres of water a day - far below the recommended 20 litres.
This isolation means hospitals are receiving women with complications in their pregnancy dangerously late. There is only a single ambulance to cover the route between the Metche hospital and the clinic near the camp at Alacha, where Mohammed is one of nearly 50,000 refugees. The MSF team has seen cases where women in desperate pain have had to wait an entire night for the ambulance to arrive.
As well as being rough, the route passes through valleys that flood during the rainy season, completely cutting off travel.
Alejandrina Cripovic, a surgeon at MSF's hospital in Metche, said every case she sees is an emergency, with some women having to make long and difficult journeys to the hospital by foot or on a donkey.
"Imagine being nine months pregnant, in labour, and travelling hours on a cart pulled by a donkey to get to a hospital. The biggest factor is the delay but having to come in these conditions also has an impact on the birth," says Cripovic.
Malnutrition, which is on the rise, also increases the risk of complications in pregnancy, including the uterine ruptures that MSF staff see regularly.
Mohammed has remained in hospital 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 search of work, so Mohammed is completely reliant on her mother.
The malnutrition ward has expanded to six tents and has patients spilling over into other sections. Children lie under mosquito nets in sweltering heat in almost complete silence as medical staff work, preparing treatments and weighing children on a scale made from a bucket and rope.
In mild cases children get sachets of PlumpyNut, the specially formulated peanut paste, but the worst cases 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 fed through a nasal drip. The infant has been ill for the past year but Abubakar was repeatedly given only painkillers without any diagnosis until she made the journey from Alacha to Metche.
"Every day, I see more children joining us in this tent," she says. "The food we're eating is poor; there's not enough to eat and it's not nutritious.
"If we were at home, we could’ve adapted ourselves. You can go and grow crops; you can work to earn some money; but here we’re reliant on what we’re given."
And what they are given is a small amount of sorghum, cooking oil and salt, handed out every two months. Such a basic diet lacks nutrition, and the little cash she is given cannot buy much in the weekly food markets, where prices have become inflated.
Abubakar was relocated to Alacha after arriving from Sudan in 2023, having fled the paramilitary Rapid Support Forces' attack on her home city of El Geneina in June that year.
Finding no work in Chad, her husband has gone to Libya in the hope of raising enough money for them to follow. She lives with his relatives, sharing out whatever food they can get.
Abubakar says she has already seen food distributions being reduced and there are concerns 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 created the 21st century's worst humanitarian disaster and the scale of needs of the refugees continuing to arrive, only 69% of the international funding needed in Chad was received by UN agencies in 2024.
The World Food Programme warned in June that without further money, it would need to cut food aid further.
In Metche, a group of Sudanese women sit under a tree. Azza Dahiye Osman, 65, is weaving dried palm leaves into items she can sell at the market. Some of the others sell small bags of peanuts or get work from local farmers but often end up being exploited and not paid.
They all have their own stories of hardship. One woman miscarried after she was turned away by health clinics despite the pain she was in.
Osman suffers from hypertension but says there is no treatment for chronic diseases in the camps until the illness reaches an emergency stage. "So if I have diabetes or hypertension, do I have to die to get treated?" she says. "I have searched and searched and searched for help but I cannot even get the medicine I need."
Osman left Sudan two years ago, fleeing the RSF advance onEl Geneina, the first city in the Darfur region to fall to the paramilitaries. Now in Metche, people are anxious for news of the RSF’s push to take El Fasher, the last city in Darfur still resisting the rebels.
The RSF claims it is pushing back against the Sudanese government, which it says is made up of elites who have long ignored the marginalised.
"They are liars; there's nothing to believe," says Osman. "They are the ones who killed us - we cannot live under them."
RSF control of Darfur—and the parallel government it has established there—means no going back for refugees in Chad. It is a bleak prospect. There are few jobs on offer for young men; just local brickfields or northern Chad's goldmines. So most leave to try their luck further afield.
Afaf Abdulmalik, 21, feels she will have to move soon. She left behind a comfortable life and a government job in El Fasher in 2023 after her brother-in-law was killed in front of his family during the RSF’s first failed attempts to take the city.
Her older brother and sister remain in El Fasher but she has not heard from them and does not know whether they are alive. Her life is focused on the daily survival of her elderly mother, sister and young niece; searching for water and firewood.
There is no schooling available for her niece, who is still traumatised by her father's killing. The UN's refugee agency, UNHCR, has warned that aid cuts by international donors have threatened secondary education programmes and could mean 155,000 out of school by next year.
The teenager saw her father shot in front of her by RSF fighters, who used to raid their neighbourhood on motorbikes, killing and kidnapping residents.
"We cannot forget what we saw there," says Abdulmalik. "My niece still freezes if she sees a man on a motorbike."
But she has also tried to cultivate a little joy: the family's shelter is surrounded by plants—mostly vegetables but also flowers that remind them of a Sudan in bloom with lemon trees and pomegranates.
The garden has taken time—she cannot buy seeds so Abdulmalik takes cuttings of plants she comes across while she goes about her daily tasks and brings them home. To see her work flourish, she had to wait for the recent rainy season.
"Sometimes in the morning I take a cup of tea and stand in the garden; it gives me some happiness; it helps me remember life before the war and forget everything that's happened," she says. "I get this feeling for a moment that maybe everything will be OK."