The present study assessed the socioeconomic inequalities in Ecuadorian women’s health care access in the context of comprehensive social reforms based on equity, and 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 between certain social groups decreased. Despite this, some social inequalities in health care have remained or have even increased over time.
Skilled birth attendance
Several factors could explain the moderate increase in coverage (from an already high level) observed in skilled birth attendance; these include 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 programme (Ley de Maternidad Gratuita) that has been in place since 2005, and the increase in enrolment on the national health insurance scheme amongst 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 [33]; 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 in access to health services amongst indigenous women [36], and research has shown that this same group tend to be less aware of obstetric warning signs, as well as the use of health services, than mestizas in the country [37].
Studies from Latin America have demonstrated that the integration of traditional birth attendants (TBAs) 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 reform period [40], although public health policies to improve articulation between TBAs and the formal health system were recently announced [41].
Cervical cancer screening
Cervical cancer is the third cause of death in women in Ecuador [42]. 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; conversely, there was little reduction in inequality from 2006 to 2014.
A pap test (cytology) is the basis for cervical cancer screening, and is provided free of charge in all public health care facilities. Testing is promoted when women use health care services. Although access to health facilities improved significantly over time, a weak application of health promotion policies and persisting barriers to screening might explain both the low coverage and inequalities [43]. Latin American studies have identified a number of obstacles, including feelings of shame, negative perceptions of health workers, concern about the test results and procedures, and previous negative experiences [44, 45]. Low education, poverty, lack of access to health insurance, and limited use of health services have also been reported as barriers to 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 preventative knowledge about breast and cervical cancer and sexually transmitted infections [51].
Comprehensive cancer management has traditionally been one of the weakest public health strategies in the country, with extreme fragmentation between the preventive and curative components of 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 [52]. This will hopefully contribute to increased access and decreased 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 as a whole (68%) [53]. 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 [54], which hopefully will have contributed to an increase in coverage more recently.
The socioeconomic inequalities in coverage for both periods were surprisingly concentrated in disadvantaged groups, except amongst indigenous women. A study of rural Ecuadorian women has shown how they have moved from biomedical to traditional care in accessing family planning due to the inconsistent availability of contraceptive methods in public health services [55]. Similarly, programmes that do not respond to community needs or lack cultural sensitivity have impeded access even when contraceptives are widely available [56, 57, 58].
Studies have also demonstrated how bureaucratic barriers in free choice contexts can limit the use of health services, while the attitudes and behaviours of maternal health care providers in interactions with clients can discourage the use of contraceptives [59]. There are, however, positive experiences in the country that have overcome some of these difficulties. A recent study of 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 [60].
Methodological considerations
The strengths of the present study include its large population-based random sample and the national representation of different socioeconomic groups. The possibility of selection bias was thus precluded. The application of the same questionnaires in the two periods that were studied and the inclusion of several socioeconomic variables are also strong features.
Given that this was a population-based study, some questionnaire answers may have been subject to response and recall bias. Although the institution responsible for conducting the surveys carried out rigorous interviewer training, the extent of this is difficult to determine. While changes in socioeconomic inequalities in health have herein been attributed to health reforms, other factors may have played a part, so any inferences from the results should be treated with caution. Finally, though the period of health reform assessed in the study was 2007–2017, the available surveys were from 2004 (pre-reform) and 2014 (during). It is possible that the results may have been different by the end of the decade. This will be possible to assess when the next national survey becomes available.