Carlota Huacani is 53 and has just visited a doctor for the first time in her life.
Her village had no clinic, and her husband did not want her to go to the doctor anyway, so she bore five babies in a house without running water. Three died before age 2.
Huacani, an Aymara Indian who wears a round hat and shawl, is extremely modest, like many traditional Bolivian women who prefer to keep their wide skirts on when giving birth. Her daughter dragged her to a health clinic after she moved to the city to work as a maid.
"Scared. Nervous. Uncomfortable," Huacani said in embarrassed one-word answers to questions about how she felt after her first medical exam and cervical cancer screening at a clinic in El Alto, an urban sprawl outside the city of La Paz that attracts recent immigrants from the countryside.
In South America's poorest country, only 10 percent of women get Pap smears, a common way to screen for cervical cancer. Fewer than half receive prenatal care. And in rural areas, only 30 percent have a trained birth assistant.
As a result, Bolivia has the highest rate of maternal deaths during pregnancy and childbirth and the highest infant mortality rate of any country in the Americas except Haiti, as well as the third-highest rate of cervical cancer deaths in the Western Hemisphere.
The government has made preventive women's health programs a major priority, but cultural resistance to cervical exams and prenatal care is high in a country where most people are Indian and many prefer to go to traditional healers and find modern medicine invasive or foreign.
"We would need a cultural revolution in this country" to get women to get cervical cancer screening, said Vicente Calle, a country doctor.
"It's taboo. They don't let you do it," said Calle, who directs a gleaming, often empty new clinic built with Spanish funds in the Quechua Indian hamlet of Curva, high in the Andes of western Bolivia and one of the poorest regions in the country.
Calle's goals for 2005 are set out on a wall chart: 475 Pap smears out of a population of 1,732. As of the end of May, he had performed 13, and most of those were for teachers from elsewhere who were sent on assignments to the area. Of 28 births in Curva this year, only four were in the clinic despite Quechua-speaking Calle's door-to-door efforts.
Calle said most of the Quechua Indian women in Curva prefer treatment with herbs prescribed by a kallawaya, a traditional native healer. The clinic has reached out to local kallawayas -- including giving them office hours -- with mixed results.
Kallawaya Francisco Ninaconde, 79, in Charazani, down the road from Curva, said traditional medicine is the only way, and claims to cure everything from unwanted pregnancies to blindness. His grandson, who is training to be a kallawaya, helped his wife birth their first baby at home. A husband acting as sole birth attendant is common in rural Bolivian homes.
In the past decade, Bolivia instituted universal free health care for pregnant women, which has helped bring down maternal deaths from complications -- such as hemorrhaging and eclampsia, a condition that can cause seizures and coma -- to 230 per 100,000 live births. Ten years ago, the rate was 390 deaths per 100,000 live births.
"The numbers show we still have a situation to be worried about. We've made progress, but we cannot deny that in maternal death, we are still the second highest in the Americas," Deputy Health Minister Lourdes Ortiz said.
Ortiz said health authorities are recruiting nurse's aides who speak Indian languages and have devised a new strategy: paying women $12 if they go to four prenatal exams.
A trained health worker at births, prenatal care and access to birth control to prevent unwanted pregnancies are key tools, according to the United Nations, which has made reducing the world's yearly 500,000 maternal deaths one of its eight global development priorities.
"Two women a day die in Bolivia from cervical-uterine cancer," said Francisco Prudencio, director of the U.S.-funded women's health clinic in El Alto where Huacani went for her first cervical cancer screening.
Bolivia's cervical cancer death rate is 22 per 100,000 women, according to the Pan American Health Organization. Only Nicaragua and Haiti in the Americas have higher rates.
In Curva, where the clinic boasts solar power while the neighboring adobe houses have no electricity, myths about modern medicine abound. But there are also practicalities that keep women away from the clinic.
"No one here has a shower in their house. They're embarrassed to go to the doctor because they can't even clean up first," said Curva-born La Paz resident Edelmira Echoba, 66. She bore six children at home and knows several women who died in childbirth in recent years in Curva.
"I got dizzy once after they took blood from me, and I've been scared to go back to the clinic ever since," said 23-year-old Victoria Carrillo, in nearby Charazani, whose husband was her only helper in three births.
Nurse Marta Choque makes house calls in Charazani bearing gifts such as vitamin-fortified cooking oil and coaxes women to the clinic to see their fetuses on an ultrasound screen.
She has persuaded some women to give birth at the clinic by promising they can keep their skirts on and bring in llama-fur rugs to make the birthing room more homey. But she cannot erase the stigma.
"People always leave at night so that no one knows they had a baby in the hospital," she said.