CEDAW/C/49/D/17/2008 hospital during a period when she needed immediate emergency care: the only hospital that would take her was in a neighbouring municipality some two hours away. Considering that the nearest available hospital required travel time equal to the amount of time an average woman in her condition has to live, she had no reasonable access to necessary emergency services. Similar inequities exist in the distribution of health-care facilities between states. 3.11 The author claims that in the present case, the absence or failure of a referral system between the health centre and higher-level facilities and the lack of coordination between prenatal and delivery care critically delayed the victim ’s access to services and may have cost her life. Only one hospital among those contacted had available space. There were no means of transporting Ms. da Silva Pimentel Teixeira to that hospital because it did not want to use its only ambulance. The health centre did not have its own means of transportation, and her mother could not find a private ambulance. There were no available beds at the hospital , and doctors from the health centre failed to send her medical records to the hospital. 3.12 Given Ms. da Silva Pimentel Teixeira’s own experience and the numerous studies on maternal mortality in Brazil that identify poor quality of health care in treating obstetric emergencies as a major reason for Brazil’s high maternal mortality rate, and a fatality rate in many facilities that can be said to be at higher than acceptable levels, the author submits that the incompetence and negligence of the health-care providers and the lack of timely access to services were key factors in her death. 3.13 The author submits that the State party violated the rights of Ms. da Silva Pimentel Teixeira under article 2 (c) of the Convention by failing to ensure the effective protection of women’s rights. They refer to the Committee’s jurisprudence in communication 5/2005 (Şahide Goekce (deceased) v. Austria) under which the Committee held that the establishment by a State party of legal and other remedies [to address domestic violence] must be supported by State actors who adhere to the State party’s due diligence obligations. The author also refers to the emphasis placed by the Inter-American Commission on Human Rights on the obligations of States to organize their government structures in order to ensure t hat violence and discrimination against women are prevented, investigated and punished and, further, that women are provided with redress. The facts of the case show that the State party has clearly failed to put into place a system that ensures effective judicial action and protection in the context of reproductive health violations. They submit that the lack of responsiveness on the part of the judicial system clearly points to the systematic failure of the State party to recognize the need to adopt measu res of reparation that compensate and provide restitution to women who have been treated in a discriminatory manner. 3.14 As to the exhaustion of domestic remedies, the author maintains that access to justice is illusory. The husband of the deceased, on his own behalf and on behalf of their 5-year-old daughter, filed a civil claim for material and moral damages on 11 February 2003, three months after her death, and asked for tutela antecipada twice. 5 The first request by the family of the deceased, made on 11 February 2003, was ignored. The judge also denied the second request, filed on 16 September 2003. __________________ 5 11-51699 Tutela antecipada is a judicial mechanism that requests the judge to anticipate the protecti ve effects of a decision. It may be used to avoid unwarranted delays in the judicial decision that may otherwise lead to irreparable or serious damages. 7