Table 2.

The “Ruta Critica” or Perilous Pathway.

Sra. Quispe woke up late at night, feeling unwell and decided to go to the clinic in the neighboring village. Since there were no public transportation services available and neither she norher husband could afford a taxi, she waited until morning. When she arrived, a room full of pregnant women and babies were waiting to be seen. She signed in with the receptionist, who scolded her for coming because it was not a regularly-scheduled visit. After several hours, a nurse measured her blood pressure as 140/90 mmHg. Since it was elevated, the nurse called the family medicine physician. He was busy seeing other patients so Sra. Quispe waited another hour. He confirmed her elevated blood pressure but could not test for proteinuria because the clinic wasnot authorized to do so or have the requisite dipsticks. The woman said she had blurred visionand pain on her right side, but neither the nurse nor the physician understood what she was saying asshe spoke only Aymara. They referred her to a level-two hospital for further evaluation. Two dayslater, after arranging for child care and a several hour bumpy bus ride, she arrived at the hospital. Herblood pressure was measured as 150/110 mm Hg so she was referred to a level-three hospital. She returned home and several days elapsed while she and her husband arranged for child care and transport. After another bumpy bus ride, she reached the level-three hospital, waited several hours tobe seen and then was admitted. A 24-hr urine was ordered that confirmed significant proteinuria, soshe was diagnosed with preeclampsia. She was asked by the physician via a translator if she had usedany traditional remedies, and then was scolded when she said that she had used herbs. No treatments were administered or other diagnostic tests performed. Four days after her due date (which was approximate since she had not had a mid-pregnancy ultrasound and the date of her lastmenstrual period was uncertain), she gave birth to a 1900 gm baby boy. He developed severe respiratory distress but could not be admitted to the neonatal intensive care unit because all bedswere occupied. He was given blow-by oxygen supplementation but died four days later.