who died of tuberculosis in 2007, aged 46 years, and received medical attention from a volunteer nurse; Tito García, who died from a cardiac murmur in 2005, aged 46 years, probably related to Chagas disease,266 and received medical attention; NN Dermott Larrosa, who died at birth in 2003, possibly due to vomiting and diarrhea and received medical attention at the Filadelfia Hospital; NN Dermott Larrosa, who died from anemia in 2001, five days after birth, and received medical attention at the Filadelfia Hospital;267 Mercedes Dermott Larrosa, who died from enterocolitis and dehydration in 1996, at two years of age, and received medical attention from a volunteer nurse, and Rosana Corrientes Dominguez, who died from whooping cough in 1996, 10 months after birth, and received medical attention at the 25 Leguas Health Clinic, the Court finds that responsibility cannot be attributed to the State, because it has not been demonstrated that the medical attention provided was insufficient or deficient, or that there was a causal connection between the death and the situation of vulnerability of the members of the Community. 231. Regarding the other individuals, the Court observes that many died from illnesses that were easily preventable if they had received constant periodic care or adequate health care services.268 It is enough to underscore that the main causes of death were tetanus, pneumonia, tuberculosis, anemia, whooping cough, serious symptoms of dehydration and enterocolitis, or from complications during labor. In addition, it is worth highlighting that the main victims were children in the early infancy, towards whom the State had increased protection obligations. This will be examined further infra para. 259. 232. The death of Remigia Ruíz, who died in 2005 at 38 years of age, and who was pregnant and did not receive medical attention, reveals many of the inherent characteristics of maternal mortality, such as: death during labor without adequate medical care, a situation of exclusion or extreme poverty, lack of access to adequate health services, and a lack of documentation on cause of death, among others. 233. In this regard, the Court underscores that extreme poverty and the lack of adequate medical care for pregnant women or women who have recently given birth result in high maternal mortality and morbidity.269 Because of this, States must design appropriate health-care policies that permit assistance to be provided by personnel who are adequately trained to attend to births, policies to prevent maternal mortality with adequate pre-natal and post-partum care, and legal and administrative 266 The expert Pablo Balmaceda noted that “Tito García […] had Chagas disease which is endemic to the area; in other words, to almost all of South America, but he never received adequate medical attention for his illness,” supra note 226. 267 Nevertheless, in the health and hygiene report on the Xakmok Kasek Community prepared by Dr. Pablo Balmaceda, supra note 206, folio 2311, the same person appears, but it is indicated that he never received medical attention. 268 According to the testimony given by expert witness Pablo Balmaceda during the public hearing held on April 14, 2010, “very many of the deaths that occurred in the Community were due to causes such as diarrhea or tuberculosis, which generally worsened owing to the lack of immediate adequate medical attention. Death from these causes ensued owing to dehydration and serious lung problems that evidently stemmed from their way of life.” He also noted that “the children […] die from vomiting, diarrhea, and ultimately dehydration, and also due to lung problems that begin with a cold that gradually gets worse and finally they die due to lack of medical attention,” supra note 226. 269 Cf. Paul Hunt. Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of health, A/HRC/14/20/Add.2, April 15, 2010. A maternal death is the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes. WHO, International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, vol. 2, Instruction Manual, 2nd ed. (Geneva, 2005), p. 141. 54