Venezuela's food shortages, inflation and crumbling medical sector have become such a source of anguish that a growing number of young women are reluctantly opting for sterilisations rather than face the hardship of pregnancy and child-rearing.
Traditional contraceptives like condoms or birth control pills have virtually vanished from store shelves, pushing women towards the hard-to-reverse surgery.
"Having a child now means making him suffer," said Milagros Martinez, waiting on a park bench on a recent morning ahead of her sterilisation at a nearby Caracas municipal health centre.
The 28-year-old butcher from the poor outskirts of Caracas decided on the operation after having an unplanned second child because she could not find birth control pills.
Her daily life revolves around finding food: she gets up in the middle of the night to stand in long lines outside supermarkets, sometimes with no choice but to bring along her baby son, who has been sunburnt during hours-long waits.
"I'm a little scared about being sterilised but I prefer that to having more children," said Martinez, who with dozens of other women took a bus from the slums at 4 am to attend a special "sterilisation day" in this wealthy area of Caracas.
While no recent national statistics on sterilisations are available, doctors and health workers say demand for the procedure is growing.
The local health program for women in Miranda state, which includes parts of Caracas, offers 40 spots during these "sterilisation days" but as recently as last year did not usually fill them.
Now all the slots are scooped up and some 500 women are on the waiting list, according to program director Deliana Torres.
"Before, the conditions for this program were that the women be low-income and have at least four kids. Now we have women with one or two kids who want to be tied up," she said.
Health workers at a national family planning organisation and at three government hospitals in the states of Falcon, Tachira and Merida echoed her view that demand for sterilisations had grown in recent months.
The trend highlights how the oil-rich nation's brutal recession is forcing people to make difficult choices.
Venezuela is a largely Roman Catholic country where Church doctrine rejects all forms of contraception and abortion is banned unless a woman's life is at risk. The Archbishop of Merida, Baltazar Porras, told Reuters an increase in sterilisations would be a "barbarity".
But Venezuela's crisis has triggered almost daily riots for food and slammed a shrinking middle class as well as the poor who were once a bastion of support for late leftist leader Hugo Chavez's self-styled "beautiful revolution".
Pregnant women are particularly affected as they struggle to find adequate food and supplements, give birth in crowded and under-equipped hospitals, and have to spend hours in lines for scarce diapers, baby food and medicines.
The government ministries for health, women and information did not respond to requests for comment.
'I wanted five kids'
Sterilisations are usually straightforward procedures that involve closing or blocking a woman's fallopian tubes, known as tubal ligation.
"I heard about these free sterilisation days on the radio. Immediately I showered, dressed, and went out (to find out about them)," said Rosmary Teran, 32, who had her second child two months ago and also came to the health centre from a poor neighborhood before dawn.
Some health workers fear the economic meltdown is putting pressure on women to make a choice they may come to regret if the crisis eases.
"Sometimes we hear: 'My husband told me to get sterilised because another child now wouldn't be practical'," said social worker Ania Rodriguez at family planning group PLAFAM in central Caracas.
Rodriguez says she meets with up to five women a day seeking sterilisations, up from one or two per week about a year ago.
When women seem unsure or pressured into sterilisations, Rodriguez tries to steer them towards contraceptives like intra-uterine devices, which are somewhat more available and affordable than birth control pills or condoms.
When they have them, pharmacies sell a pack of three condoms for around 600 Bolivars, only 60 US cents at the black market rate but a big expense for those who earn the minimum wage of some 33,000 Bolivars per month.
On the Caracas re-sale market, those same condoms fetch around 2,000 Bolivars. Venezuela's elite can afford those prices but the ailing middle class and poor are increasingly stuck.
"I couldn't find the (contraceptive) injections, the pill, nothing. It's very expensive on the black market, and now you can't even find stuff there anymore," said Yecsenis Ginez, 31, who has one son and decided to get sterilised.
"I thought I would have up to five kids, I had loads of names in mind. But it would be crazy to fall pregnant now."
Still, some women have had to wait for months to be sterilised because there are limited spots at state-led hospitals and private clinics can charge about 12 times the monthly minimum wage.
And some health centres are unable to provide sterilisations at all due to a lack of equipment or specialists.
Amid what now feels like a distant oil boom, Chavez built thousands of Cuban-staffed health centres in poor neighborhoods and also launched popular maternity-health programs during his 1999-2013 rule.
But with Venezuela's state-led economic model decaying and oil prices depressed, hospitals have deteriorated sharply under his successor Nicolas Maduro.
Medicine shortages hover around 85 per cent, according to a leading pharmaceutical association. Equipment ranging from surgical gloves to incubators is scarce, and many underpaid doctors have left the public sector or emigrated.
The government still says it has one of the world's best health systems and accuses detractors of waging a smear campaign. It has stopped releasing timely health data, though.
The World Health Organization says Venezuela's neo-natal mortality rate was 8.9 per 1,000 live births last year, above the Americas region's average of 7.7.
It says Venezuela's maternal mortality rate was 95 per 100,000 live births in 2015, one of the worst rates in Latin America and up from 90 in 2000.
The nation of 30 million people has one of Latin America's highest rates of teenage pregnancies and large numbers of single-parent households, UN data shows.
As they waited to be called into the operating room for their sterilisations, women in blue scrubs and hairnets wistfully recalled happier times in once-booming Venezuela.
"Before, when you got pregnant, everyone was happy," said mother-of-two Yessy Ascanio, 38, as she sat on a bed in a side room. "Now when a woman says 'I'm pregnant', everyone scolds you. It makes me sad for young women."
As some of her peers nervously looked out at patients being wheeled out after their sterilisation, Ascanio advised: "If you get scared, just remember those food lines."