The stigmas associated with the female reproductive process are boundless. Past discussions have dealt mainly with discrimination between men and women. For the next few weeks, I’ll progress to discuss a different kind of discrimination and barriers that many women face during pregnancy, labor and delivery while trying to access existing maternal health care in many developing countries (and even to a certain extent, in developed countries as well). The vast majority of these barriers fall under the categories of racial, cultural and socioeconomic. This week and next, we’ll look at a case study that takes into account socioeconomic and cultural barriers to happy birth days.
“Are they looking after you all right, dear?” asks Julio Guerrero. “Yes,” she replies. “Have they charged you for any medicines or for anything they have given you?” “No,” she says. “Has anybody asked you to pay for anything at all?” he asks again. “No, it’s all free, because of the free maternity programme,” she says cheerfully (OneWorld).
Ecuador’s population is about a 25% Amerindian with the vast majority being Quechua, but also including a subset of Aymara and other smaller groups (Global Movement). Like many indigenous and traditional groups across the globe, for many pregnant Quechua women home births are the preferred option. Yet, home births oftentimes come with dangerous hazards especially in situations where skilled birth attendants and the proper equipment are not present. In 1990, Ecuador had one of the highest maternal mortality rates (MMR) in all of Latin America (181 deaths/100,000 live births, Health Metrics). However, faced with this sobering statistic and pushed by various local women’s and health organizations, the Ecuadorian government decided to take decisive action. While distance to health centers and clinics did create an obstacle for some women, various national studies concluded that cultural and economic barriers rather than physical ones were the largest detractors of women seeking hospital or other institutionalized births.
In 1994, the Ecuadorian government approved the Ley de Maternidad Gratuita y Atención a la Infancia (LMGAI) [Law for the Provision of Free Maternity and Child Care (LMFC)], which guarantees universal female access to free prenatal care, labor and delivery and basic child health services. The version of the LMFC that exists today largely follows the reforms enacted in 1998. Through this law, any pregnant woman in Ecuador can walk into any public clinic or hospital and receive services at zero cost. The budget allotted to the implementation of the LFMC tripled between 1999 and 2002 from $8,000,000 to $23,000,000 USD (HCI Project). Under this innovative law payment to health care providers are based on the volume and quality of the services rendered. This quality is assured by spontaneous interviews and surveys conducted by each county’s citizens/users’ committee, a group of private men and women from the community, also appointed under the law.
While there are no studies directly linking the LFMC as the key factor behind this change, Ecuador’s maternal mortality rate has been more than halved since 1990 with an average annual decrease of 4.6% per annum, one of the largest yearly decreases in all of Latin America (Health Metrics). In 2002 alone, nearly 2.3 million women and children were served (HCI Project). According to a study conducted by UNICEF (2008), the odds of women in Ecuador dying of maternal causes are now 1 in 270 (UNICEF: Ecuador Stats). More women than ever are seeking out professional care during labor and delivery. Antenatal care coverage is currently at 84%. 98% of births are attended by skilled individuals and 85% occur in a medical institution (UNICEF: Ecuador Stats).
But this law is only one side of the coin that has made MMR in Ecuador drop precipitously. As mentioned above, besides economic barriers, the biggest obstacles keeping pregnant women, particularly indigenous pregnant women, out of hospitals were cultural. Only focusing on making hospitals financially tenable, while a terrific endeavor, fell dangerously short of turning hospital births into fully attractive options. The LFMC was the equivalent of opening the hospital doors, yet Ecuador’s shift in hospital policy and atmosphere to reflect respect for indigenous cultural ideals and customs seems to be what really enticed women to enter in. This is the subject of next week’s blog.
Sources:
http://www.hciproject.org/sites/default/files/292777.pdf
http://www.gmfc.org/en/action-within-the-movement/latin-america-a-caribbean/regional-news-in-latin-america-a-caribbean/318-fewer-mothers-dying-thanks-to-qmodelq-law-
http://southasia.oneworld.net/globalheadlines/a-model-law-on-maternal-care-for-Latin-America
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(07)61561-X/fulltext
http://www.womensenews.org/story/health/090215/gravity-birth-pulls-women-ecuador-hospital
http://www.urc-chs.com/news?newsItemID=17
http://www.unicef.org/infobycountry/ecuador_statistics.html
http://www.healthmetricsandevaluation.org/news-events/news-release/maternal-deaths-fall-worldwide-half-million-annually-less-35
4 Comments
That is a really cool policy. It is obvious that making services free is a first step to drawing women into hospitals, but how cool that Ecuador actually did that and had an effect? I can’t wait to read your next blog post and find out the cultural attitudes that shifted to make these women feel more comfortable. This is so important for women worldwide and what an inspiring example that might be able to be modeled for other countries!
Thanks for sharing this. I wasn’t aware of this new innovative policy to provide free maternal services free. That’s very transformative and progressive. I’ve been to Ecuador before and have worked in some of the rural areas like Cayambe. As I was reading your blog, I immediately thought, as you mentioned, how are they reaching out to rural areas and incorporating cultural beliefs? I definitely am interested to hear how they are addressing this specific topic.
Also, last year, Ecuador went through protests and disputes over President Rafael Correa. Despite efforts of increasing police efforts, there were disputes of corruption and actual payment of officers. Seeing as though Ecuador is facing financial troubles and implementing more government programs, I’d be curious to see about the accountability of this maternal health program.
I think it’s so important to provide prenatal care to all women. That is such a big factor in the US that changes the outcome of maternal health amongst socioeconomic statuses. I wonder how the LFCM law worked, logistically, in Equador’s economics, and how it may be adapted into the US.
Thank you very much for posting a success story! It is so easy to get discouraged by the numerous obstacles to addressing the issues like maternal mortality that we discuss in class, and so your sharing of a success story is especially appreciated! Yet, while I don’t want to be a pessimist, I also wonder about the sustainability of this policy, and most especially of the funding of this policy, in the long run. I worry, given the precarious nature of the prices of Ecuadorian exports, that this program may be first to go if times get tough. Do you know anything about exactly how it is funded/planned to be funded in the long run?