The New York Times spent weeks following women inside the country's health care system, which has been crippled by a broken economy overseen by an increasingly authoritarian government.
The labour pains began in her village, in the dark.
Her baby was coming, and Milagros Vásquez, 20, needed help.
With a minidress stretched over her swollen and increasingly stressed body, Vásquez braved a motorbike journey across three rivers and gripped her belly through two jolting bus rides. But arriving at the first hospital was just the beginning.
Over the course of 40 hours, Vásquez, a former high school sports star, visited a second hospital, a third, a fourth. We have no sterile tools, they told her at one. No incubator, they said at another.
She took another bus. She slept on a bench. She cried in the street, losing count of the number of doctors who had placed their hands inside her, measuring her body's dilation, only to tell her to leave.
She tried a fifth hospital. We can't help you, they said.
Finally, in Caracas, the capital, she stood outside the largest maternity ward in the country and sent up a last, desperate plea.
"Please God," Vásquez prayed, "please don't let me die."
Venezuela's public health system, once the best in Latin America, has been in a state of progressive collapse for years, crippled by a broken economy overseen by an increasingly authoritarian government. But few parts of that system have been as damaged as its maternity wards, where the most critical birthing tools — vital sign monitors, ventilators, sanitation systems — have broken down or just disappeared, sometimes forcing doctors to turn women away.
About half of the country's physicians, some 30,000 people, have left in recent years, many of them desperate to save their own families, according to the Venezuelan Medical Federation.
The true effect of this on mothers and babies is unknown. The most recent data come from 2016, when maternal deaths shot up by 65 per cent and infant mortality rose by 30% in a single year. The minister who published that information was promptly fired — and new statistics have been treated as a state secret since.
To understand what it is like to give birth in this shattered system, we followed pregnant women to six hospitals in Venezuela, and one across the border in Colombia, as they sought to deliver.
To give birth in Venezuela today is to risk death — for both the woman and her child.
Vásquez was once a high school handball player so celebrated for her strength and skill that she traveled Latin America representing Venezuela.
But one day this January, on the doorstep of a towering Caracas hospital, Concepción Palacios, she crumpled, sobbing, her arms around the waist of her mother, Cristina, who pounded on the door, begging for her daughter to be admitted.
Vásquez fainted. But then the door opened, and about 48 hours after her labour pains began, she gave birth to baby Cristal. But her infant, born premature and tiny at just 3.3 pounds, didn't make it past morning.
Days later, Vásquez pulled a white baby blanket from the pocket of her sweatshirt, one of her only memories of her daughter.
Hospital officials had declined to give her a death certificate, and with no money for a burial, she had to leave Cristal's body in the morgue.
"Here," she said, "a woman is treated like a dog."
For many Venezuelan women today, the defining feature of childbirth is the ruleta, or roulette: The gruelling process of traveling from hospital to hospital, trying to find one that is equipped to help them.
They sometimes hitchhike, or walk for miles, or take buses over roads whose ruts and bumps seem designed just to torture them. In rare cases, they are rejected over and over until finally giving birth in the street, on a hospital's steps — or in its lobby.
"I threw myself on the ground," said Evaró Chacín, 32, who said her daughter was born on the lobby floor at Hospital Noriega Trigo in Maracaibo after staff there told her they couldn't take her. "It was my husband who had to help me."
In some instances, women die. Darwin Maiquetía, 37, lost his wife, Kenny Chirinos, on Jan. 20, after she developed an infection following a caesarean section in a military hospital. For years, hospitals have struggled to acquire disinfectant.
"The level of anger I have is not normal," said Maiquetía, cradling his newborn daughter, Alena, one afternoon. He chose a military hospital, he said, because he thought that in an increasingly militarised country, it would be safe.
Chirinos, an avid outdoorswoman who often went rappelling on the outskirts of Caracas with her husband, was the love of his life, he said.
"They're destroying families," he said, "destroying lives."
In other cases, families lose their children.
"All the clinics said the same: We don't have what's necessary to care for your baby," said Aydimar Alvarado, 26, who traveled to 12 hospitals before giving birth to a little boy, Kahel, in December.
Born with a mop of dark hair that nurses smoothed into a mohawk, making him look like a miniature rock star, Kahel died 10 days later. His death certificate cited prematurity, bleeding around the brain and other factors.
One doctor we consulted said the conditions might have been prevented or addressed had his mother's care not been delayed by the roulette.
In his many televised speeches, the country's president, Nicolás Maduro, has characterized the country's health system as facing challenges but generally doing well. As recently as March, he encouraged women to "give birth, give birth," saying that every woman "should have six children" for the good of the country.
He has attributed the country's medical supply shortage to sanctions, which President Donald Trump has imposed to try to push Maduro out.
Analysts and critics claim this assertion has only some weight.
Sanctions have sometimes delayed the delivery of essentials, but the government could go through aid organizations to get what it needs, said Feliciano Reyna, founder of Venezuelan nonprofit Action for Solidarity.
One economist, Asdrúbal Oliveros, said Maduro had simply chosen to prioritise the import of oil and food over medicine, making the calculation that pregnant women and sick people don't protest — but that hungry people do.
The heads of the country's women's ministry and health ministry did not respond to requests for interviews. Nor did the directors at several major hospitals.
After years of denying the country was in crisis, Maduro opened the door last year to humanitarian aid, and groups like the Red Cross and UNICEF began to bring in hundreds of tons of goods, including lifesaving antibiotics.
But the effect has at best been palliative, in part because donations are scarce.
"We put out a call for help," said Luis Farias, of the Red Cross in Venezuela, "and it didn't get the backing that we had hoped."
Critically, the dearth of medical supplies is colliding with the growing needs of Venezuelan women.
Years into the country's recession, a growing number of expectant mothers are grappling with crisis-related problems — like malnutrition — that heighten the risk of a complicated birth and the need for expert help.
The obstetricians and paediatricians who remain have found it nearly impossible to do their work.
Inside the delivery room at the public hospital in the city of La Victoria, Nataly Smith, 21, climbed onto a metal birthing bed one night, shaking and alone. She wore pink lipstick and had her hair in a ponytail. Blood pooled on the floor below her.
A list of missing items hung on a nearby wall: soap, gauze, trash bags. Worms had invaded the hospital's vinyl recliners, so the beds had been banished to a nearby room.
"I'm scared," Smith whispered.
At her feet was Dr. Beatriz Ticona, 52, chief of the ward, in purple glasses and colorful scrubs.
Dozens of her doctors had quit, she said, aghast at the conditions or desperate for higher pay. Most doctors at public hospitals make less than US$10 a month, a salary that is impossible to live on. Ticona has four paediatricians to help her. She needs 18, she said.
She has two respirators for babies in need and no intensive care unit. There is one grimy bathroom for the entire maternity ward. Critically, the blood bank is often empty.
That night, Smith gave birth to a healthy girl, Cristangely.
But not all patients are as lucky. And when a patient dies, families sometimes come looking for someone to blame.
"To find yourself in that situation where they accuse you of being an assassin," Ticona said, "is not easy."
About three years ago, Ticona had a breakdown and had to leave the job for months. She came back out of a sense of duty. But she wondered how long she could hang on.
"It gets to a point," she said one night, "where there is so much need that you collapse."
Increasingly, pregnant women are giving up on Venezuela altogether and making the journey to neighboring Colombia, where the government has promised to pay for their health care.
These women, some of whom have watched their sisters and neighbours die in childbirth back home, are a growing part of Venezuela's exodus. Five years ago, at Hospital San José in Maicao, Colombia, just minutes from the border, doctors delivered about 70 Venezuelan children. Last year, they delivered more than 2,700.
The influx has pushed the hospital to its financial limits, said Dr. Guillermo Villamil, an administrator. So far, the Colombian government has repaid the hospital less than a third of the US$8 million that it has cost to help Venezuelan patients, he said, adding that he was committed to helping until the money ran out. (The office of the Colombian president, Iván Duque, said it was assessing hospital costs and how much it owed.)
Though official border crossings have been closed to prevent the spread of the coronavirus, pregnant women keep arriving, often traveling over dangerous, informal paths known as trochas.
One day in January, a hospital cot went racing through the maternity ward of the Hospital San José. In the bed was Neryelín González, 25, who had abandoned her university studies in chemistry in Venezuela and crossed the border into Colombia 10 days before, on one of those illegal paths, in search of a safe place to give birth.
In the delivery room, she gave birth on a cushioned recliner covered in sanitary plastic. A clean crib waited for her baby. Two doctors and three nurses coached her through the process.
"Push," Dr. Said Acuña said. "Breathe."
Her little boy, Jhonei, was born healthy, at 6.7 pounds.
"Oh my God," she said, as doctors held him up, her anguished face twisting into a smile. "He's out!"
Later, hospital aides moved her to a clean room with air conditioning and a shower. She changed into a white dress she had brought along. Soon, nurses entered with her baby boy and a plate of hot food.
She had done it, she said. The journey had been worth it.
Her child was safe, she added. And she was never going back.
Written by: Julie Turkewitz and Isayen Herrera
Photographs by: Meridith Kohut
© 2020 THE NEW YORK TIMES
