In a country where contraceptives are in short supply, word in the shantytown on the outskirts of Venezuela's capital spreads quickly. The lucky get on a list run by community leaders. The less fortunate hope there will be extras.
The veteran doctor has 104 implants and there won't be enough for everyone. As a physician at the nation's largest pediatric hospital, Clemente knows first-hand that the consequences for those who don't get one are high.
"It's a sense of impotency, of frustration," she says. "You see that it's not enough, that the demand is much higher." As Venezuela's crisis deepens, women are bearing the brunt of the nation's upheaval. Despite promises by the socialist government to provide every woman access to family planning, recent surveys and interviews with health professionals indicate access to contraceptives remains incomprehensive.
International organizations like the U.N. Population Fund have begun stepping in by importing tens of thousands of contraceptives this year, but their work is still limited. It's an ordeal with increasingly international ramifications, as a growing number of pregnant women flee to countries like Colombia seeking care they cannot get in Venezuela.
"Women are getting pregnant and don't have options," said Luisa Kislinger, a women's rights activist. "They're forced into motherhood." Nicol Ramírez is 15 and already a mother. Her name is on Clemente's list, but to get an implant she needs to show a negative pregnancy test. The young mom and her older sister frantically call their mother. They need 40,000 bolivars, the equivalent of about $3, in order to do the simple test at a nearby laboratory.
"The situation in this country isn't one for having children," Ramírez says, balancing her baby daughter on one hip. "I'm still a girl myself." During the late Hugo Chávez's presidency, Venezuela's government expanded services aimed at helping poor mothers by providing monthly cash transfers. Chavez lavished praise on women and hailed the so-called "revolutionary mothers" who would help promote his vision.
The 1999 constitution he advanced guarantees "full family planning services" to women among a host of other benefits. "The socialist revolution should be feminist," he declared. Despite those initiatives, Chávez's government made only modest advances, at best, in improving contraceptive access. Government data shows that teenage pregnancies continued to steadily increase during his time in power.
"There was a major advance with the constitution, with getting all these new rights and state obligations," said Rachel Elfenbein, the author of an upcoming book on social programs created under Chávez for women. "But when it came to implementation, if and where it happened, it was patchy."
President Nicolás Maduro has struggled to advance his predecessor's agenda amidst a crippling economic contraction worse than the U.S. Great Depression. Few if any women still get cash transfers except for occasional "bonuses" equivalent to a dollar or two. Maternal death rates rose over 65% between 2015 and 2016.
"Under Maduro we've seen an unprecedented setback," Kislinger said. Health professionals believe Venezuela could cut its high maternal mortality rate by a third doing one thing: Providing contraceptives.
The extent of Venezuela's birth control shortage and the impact on women is difficult to quantify in part because the government has not released information on key indicators like teenage pregnancy since 2012. According to those now dated figures, just over 23% of all births in Venezuela were to women under the age of 20.
Some independent health organizations and women's rights groups contend the rate could now be as high as 28%. A study of four hospitals last year found that over a quarter of all births recorded were to teenage mothers.
The most recent U.N. world population report estimates Venezuela's teen pregnancy rate is about 85.3 per 1,000 adolescents ages 15-19. That figure would mark a slight decline, though is still over double the global rate. By comparison, Colombia's rate is 66.7 per 1,000 teens ages 15-19.
"We don't know what the reality is in 2019," said Nelmary Díaz, a program director the Civil Association for Family Planning, an organization that runs several clinics and has operated since 1986. "That worries us."
After years of denying the existence of a humanitarian crisis, Maduro has recently begun allowing international aid. While a large part of the emergency assistance has gone toward food and medicine, a small portion is going toward reproductive health.
The U.N. Population Fund has imported 45,000 hormonal implants so far with the government's authorization. An estimated 17,000 have been distributed thus far at hospitals and clinics like the one in Caucaguita where women line up before dawn.
"I don't want to have more kids," said Yailyn Salas, 20, the mother of a 9-month-old son in the line. "I want to close the shop." Among the millions of Venezuelans who have chosen to flee are thousands of pregnant women. In Colombia, over 26,000 Venezuelan women have given birth since August 2015. That surge is straining Colombia's already fragile health care system and testing the nation's mostly welcoming approach toward Venezuelan migrants.
In recent months, the mayor of one large Colombian city likened Venezuelans to "a poor baby factory" while a popular newspaper columnist implored migrants to "stop giving birth." "If you don't stop reproducing like you are, it's going to be even harder to see you as an opportunity for growth instead of a problem," journalist Claudia Palacios wrote.
Ramírez found out she was pregnant at 14 with her boyfriend of one year. Condoms and birth control pills were either impossible to find or too expensive. When she told her boyfriend the news, Ramírez said he responded coldly. He was 23 and already a father. He told her that he couldn't handle another responsibility.
She hasn't heard from him since. Adolescent moms under 15 are twice as likely to die during pregnancy. Though Ramírez had access to prenatal care, doctors nonetheless had to perform an emergency C-section after the baby's heartbeat became irregular.
"She was born practically dead," Ramírez said, her soft voice turning somber. Ramírez's ordeal to find birth control isn't unusual. An independent survey of 151 pharmacies consulted over a five-month period last year found some contraceptives like the patch could not be found at all in Venezuela, while others including birth control pills are experiencing near-total shortages.
Even with this year's increased access to aid, experts say Venezuela will need far more to address the needs of the estimated 9 million women in the country at risk of pregnancy. "It's a very small impact," said Jorge Díaz Polanco, a sociologist with the independent Venezuelan Observatory of Health.
Clemente's brigade was able to get ahold of a handful of the U.N.-provided implants that prevent ovulation and last four years. On two recent days, her team set up shop at a clinic where posters in support of socialist leaders filled the walls. They quickly got to work, injecting each woman with an anesthetic and then sticking a small metal tube into their upper arm so the implant could be pushed through.
By 11:30 a.m. the contraceptives were gone. "The implants have run out!" an organizer dressed in a faded Stone Temple Pilots T-shirt shouted. Nearly 40 women were still in line. Some sighed. Others were visibly angry.
"I feel deceived," said Salas, who missed the cutoff. She said a nearby health organization was selling birth control implants at a subsidized cost of around 90,000 bolivars, or $6.50. But that was just slightly less than what her husband makes an in an entire week.
"If I get one, I don't eat," she said. Ramírez and her sister were among the lucky few to get the last of the implants after they showed Clemente's team their negative test. Their mom had managed to get them the money.
Three other women that day would learn they were pregnant. Ramírez cringed as a nurse injected her with the anesthetic before placing the implant. Just as the procedure finished, the lights in the building went out — the second blackout in the neighborhood that week.
Ramírez left the darkened clinic with her baby in her arm, relieved to know she wouldn't become a mom again soon. "I'm not ready to have a child," she said as her baby began to cry. "I'm a girl who is 15."
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