This study assessed the socioeconomic inequalities in Ecuadorian women’s health care access in the context of comprehensive social reforms based on equity, and a primary health care oriented health sector reform. The results show that during the period 2006 to 2014 access to health care increased and health inequalities across certain social groups were reduced. Despite this, some social inequalities in health care have remained or even increased over time.
Skilled birth attendance
Several factors can explain the moderate increase in coverage (from an already high level) observed in skilled birth attendance, such as the rise in the number of health care facilities with maternity services, the expansion of the health workforce, particularly into rural areas, the thorough implementation of the free maternity program (Ley de Maternidad Gratuita) in place since 2005, as well as the increase in enrolment on the national health insurance scheme (by public employees and farmers), which includes free maternal and child care [19, 24, 32].
Large reductions in inequalities were observed for rural, indigenous and the lowest education groups, though inequalities remained high in 2014. To improve intercultural health care, the MoH incorporated guidelines for traditional practices in all governmental health care services in 2008 , however, several national studies have demonstrated inconsistent levels of integration of traditional practices during pregnancy and childbirth [34, 35]. Similarly, several barriers have been observed to indigenous women accessing health services , and research has shown that indigenous women tend to be less aware of obstetric warning signs, as well as the use of health services, than mestizas in the country .
Studies from Latin America have demonstrated that the integration of traditional birth attendants within the formal health system increases skilled birth attendance and the use of sexual and reproductive health services [38, 39], however, this strategy was abandoned during the period of the reform , although public health policies to improve the articulation between traditional birth attendances (TBAs) and the formal health system were recently announced .
Cervical cancer screening
Cervical cancer is the third cause of death in women in Ecuador , however, the proportion of women screened for cervical cancer was low in all socioeconomic groups in both periods. As with skilled birth attendance, high inequalities were observed in relation to place of residence, ethnicity and education; but conversely, little inequality reduction was achieved between periods.
A pap test (cytology) is the basis for cervical cancer screening, and is provided free of charge in all public health care facilities. The promotion of testing is also offered during visits to health care services. Although access to health facilities improved significantly over time, a weak application of health promotion policies and persisting barriers to the access and uptake of the screening could explain both the low coverage and inequalities (43). Studies from Latin America have identified various obstacles related to the accessibility of these preventive services, such as feelings of shame, negative perceptions of health workers, worry about the test results, fear about the procedure or previous negative experiences [44, 45]. In the same way, low education, poverty, lack of access to health insurance, and limited use of health services have been reported as barriers to this screening in countries in the Americas region. [46, 47, 48, 49, 50]. Similarly, high ethnic disparities in Ecuador have been observed between indigenous and mestizo women regarding preventive knowledge about breast and cervical cancer and sexual transmitted infections .
Comprehensive cancer management has traditionally been one of the weakest public health strategies in the country, with high fragmentation between the preventive and curative components in the health system. In an attempt to strengthen this area, the MoH developed a national strategy for cancer care in 2017 to ensure equitable access along the care continuum , which will hopefully contribute to increasing access and decreasing inequalities in the future.
Modern Contraceptive Use
The coverage of modern contraceptive use increased from 40.7% to 48.4%, which is lower than the average coverage reported in the Americas region (68%) . The increase is modest in relation to the huge investment in the purchase and supply of modern contraceptives in primary care and access to female sterilisation (ligation) at the secondary level of care, especially after childbirth. In 2013 the MoH issued new guidelines to guarantee the availability of family planning methods and the promotion of sexual and reproductive health at primary care level nationally , which hopefully will have contributed to increasing the coverage more recently.
The socioeconomic inequalities in coverage were surprisingly concentrated in disadvantaged groups, except among indigenous women for the two periods. A study of rural Ecuadorian women has shown how they moved from biomedical to traditional care to accessing family planning due to the inconsistent availability of contraceptive methods in public health services . Similarly, programs that do not respond to community needs or lack cultural adaptation have impeded access even when contraceptives are widely available [56, 57, 58].
Studies have also demonstrated how bureaucratic barriers in contexts of the free choice of methods can also limit the use of health services; and that the attitudes and behaviours of maternal health care providers in interactions with clients can also be a barrier to the use of contraceptives . There are, however, positive experiences in the country that have overcome some of these barriers. A recent study among women from low resource communities in Ecuador showed how increasing economic opportunities, preventing gender-based violence and valuing their community role contributed to empowerment in the use of contraceptive methods .
The strengths of the present study include a large population-based random sample and the national representation of different socioeconomic groups, precluding the possibility of selection bias. The application of the same questionnaires in the two studied periods and the inclusion of several socioeconomic variables are also strong assets of the study.
Given that this is a population-based study, there could be response and recall bias. Although the institution responsible for conducting the surveys carried out a rigorous training of the interviewers, the extent of these biases is difficult to determine. Therefore, although changes in socioeconomic inequalities in health have been attributed to the health reform here, there might have been other factors influencing those changes that could not be considered, meaning that the causal inference of these results should be interpreted with caution. Finally, though the period of health reform assessed in this study was 2007 – 2017, the available surveys include years 2004 (pre-reform) and 2014 (during). It is possible that at the end of the reform period, the results could have been different. This will be possible to assess when the next round of the national survey becomes available.