Maternal mortality in Ecuador: more than just a health care problem
Author: Karla E. Duque Jacome1 MD, MPH
1. Program Manager of Geographic Groups and Fields, CET, Cochrane
Introduction
Maternal mortality is considered the greatest complication of the reproductive phases, namely, pregnancy, partum, and puerperium. Ecuador is a Latin American country with a population of 18,213,749 in 2023 (INEC, 2023). Slightly more than half (51.3%) is female and 77.4% is mestizo. Like many other countries, Ecuador has endeavored to improve maternal health. However, despite the implementation of several strategies, progress in this area has stalled since 2006 and the maternal mortality rate has remained constant since then.
When looking at the problem globally, it is clear that the challenge goes beyond health care. Women, especially in rural and indigenous communities (with the highest rate of mortality), face greater obstacles than access to doctors or hospitals. This problem is exacerbated by factors such as poverty, poor infrastructure, and inequality, requiring solutions that tackle the bigger picture. Thus, as we deal with interconnected crises in today’s world, it is clear that we need to go beyond just fixing health systems. I believe that working across sectors—such as education, transport, social welfare, and even politics—is crucial if we want to make lasting progress.
Multisectoral inaction impacts women in Ecuador
Addressing maternal mortality requires more than just doctors, clinics, or emergency services. For example, many women in rural Ecuador cannot access health care simply because the roads to their villages are not well maintained, public transport services are scarce, and private transportation is unaffordable. However, it is not just a matter of physical access; education plays an important role too. Women who are unaware of their rights or do not understand how to access services are at a disadvantage. Comprehensive sexual health education demystifying contraception and women's sexual needs can help prevent unintended pregnancies, which is a key factor in reducing maternal deaths. When we educate girls and women about their bodies and their health options, we give them more control over their futures.
Poverty also needs to be taken into consideration. Even though health care in Ecuador is technically “free,” hidden costs—such as maternity and paternity leave in a low economy or finding childcare—can prevent women from accessing the services they need. That is why strong collaboration between sectors is needed to tackle all the interconnected factors that perpetuate high mortality.
But I believe that it is the intrinsic beliefs of countries and communities that are the biggest obstacle to be addressed. Many communities have intrinsically patriarchal viewpoints where the man is the one who decides when or how a woman will become a mother, whether she is allowed to use contraception, or even whether she can stop trying to get pregnant if she has not fulfilled the need for a “male heir.” This happens in cities and rural communities alike; it happened in my own family when I was a rural doctor, and I am sure it continues to happen today.
This behavior is rooted in societal norms that have not been challenged for centuries, and the responsibility is left to primary workers, who, burdened by a lack of infrastructure, tools, or training, have insufficient resources to create a lasting impact. Sadly, this perpetuates a feeling of disappointment and conformism, and in the long term, inaction.
But why does inaction end up being the default conclusion of these efforts? Is it the low salaries, the lack of resources, entrenched cultural norms, or the high workload that exhausts people and makes them accept “the norm”? As a professional who started as a rural doctor, did I feel down in this system? I did! I was and probably still am part of the bigger problem.
The big Why? of legislation
If everybody is to some extent responsible for the lack of real change, who has the real power to do something about it? It is frustrating to see how policies that affect women’s lives are often created without their input. We know that involving women, especially those from marginalized communities, is critical to designing effective health interventions. Yet, too often, their voices are excluded from the conversation. Indigenous women are still largely left out of the discussions that shape maternal health policies and they are often stuck with the consequences of their communities’ religious and patriarchal beliefs. So how are actual policies made? Do they use evidence or are they seeking to gain approval and popularity?
For real change, we need to rethink how decisions are made, who is part of that, and how many different problems in different sectors can be solved by one unified strategy. Local communities need to be at the heart of the process, and educators, doctors, and policymakers need to work with them, taking into account their ideas and their realities. Ideally, spiritual leaders should be made into allies rather than opponents of positive, evidence-based change in these communities. In Ecuador, the National Plan of Well-being attempted to achieve this by involving communities in health decisions. I believe it was a good start; however, it has not been replicated in other communities.
As rural doctors, primary care physicians, or any other actor, we need to focus on decolonizing global health systems. This means rethinking how we approach health care in ways that respect and integrate local knowledge and practices, to take evidence-based strategies and add them to cultural norms. For instance, some hospitals in Ecuador have successfully integrated traditional birth practices alongside modern medical care, which has increased attendance, community acceptance, and preventative measures. This combination has helped break down cultural barriers and improved maternal health outcomes. It has also improved communication between women and their providers, with women being able to vocalize their specific needs and wants over what is normally expected in their community. This is because the communication occurs in a safe and friendly space.
The power of policy change: legalizing safe abortions
One policy area that has been proven to save lives in other countries is the legalization of safe abortion. Right now, abortion is still relatively restricted in Ecuador, along with many other South American countries. This forces many women to turn to unsafe procedures. These risky abortions are a major cause of maternal death.
Examples can be found in well-documented articles where legalizing abortion in countries such as South Africa and Uruguay has had a positive impact on maternal mortality. When women have access to safe, legal abortion services, maternal deaths drop dramatically. This is because women are freed from legal implications and being judged by others, instead benefiting from a collective sense of support. Like traditional birth practices, demystifying and including the voice of women over their reproductive health could benefit from these examples. And although abortion is a controversial topic, evidence-based decisions that are supported by laws and trusted stakeholders can change the tide in important ways. In the end, the question remains—are laws made to use evidence to improve lives, or merely to protect people’s feelings?
Lessons learned and moving forward
There have been successes in Ecuador’s maternal health initiatives, particularly in integrating traditional medicine with modern health care services. These efforts have helped address some of the cultural barriers that prevent women from seeking care. But health care interventions alone will not solve the problem. The plateau in Ecuador’s maternal mortality rates shows that deeper, systemic changes are needed. We need to address the root causes and involve women, community leaders, lawmakers, and even religious leaders, and use evidence-based strategies to continue the goal of reducing mortality.
Key takeaways:
1. Maternal mortality is not just a health issue: We need a broader, intersectoral approach involving education, transportation, community involvement, and social policies to create real change.
2. Empowering communities is crucial: Women, especially in marginalized areas, need to be at the center of decision-making to ensure culturally sensitive and effective solutions.
3. Legalizing safe abortion can save lives: Countries that have done so have seen a significant drop in maternal deaths, showing that regulatory reform is critical.
Conclusion
We are living in a time where crises overlap and multiply, and tackling maternal mortality requires us to think and act in ways that go beyond the health sector. Only by working together across sectors, involving the people most affected, and pushing for bold policy changes can we make real progress in Ecuador and other countries.
References
Liljestrand, J. (2000). Strategies to reduce maternal mortality worldwide. Current Opinion in Obstetrics & Gynecology, 12(6), 513–517. https://doi.org/10.1097/00001703-200012000-00010
Pino, A., Albán, M., Rivas, A., & Rodríguez, E. (2016). Maternal Deaths Databases Analysis: Ecuador 2003-2013. Journal of Public Health Research, 5(2), 692. https://doi.org/10.4081/jphr.2016.692
Roldós, M. I., Corso, P., & Ingels, J. (2017). How much are Ecuadorians willing to pay to reduce maternal mortality? Results from a pilot study on contingent valuation. International Journal of MCH and AIDS, 6(1), 1–8. https://doi.org/10.21106/ijma.166
To link to this article - DOI: https://doi.org/10.70253/QDDX5674
Links to additional resources
https://www.salud.gob.ec/category/comunicamos/noticias/noticias-destacadas-noticias/
https://www.who.int/news-room/fact-sheets/detail/abortion
https://www.americanprogress.org/article/abortion-bans-will-result-in-more-women-dying/
https://www.amnesty.org/en/what-we-do/sexual-and-reproductive-rights/abortion-facts/
https://www.cfhi.org/program/global-health-in-ecuador-quito-otavalo/
https://tiltingfutures.org/updates/jambi-huasi/
Disclaimer
The views expressed in this World EBHC Day Blog, as well as any errors or omissions, are the sole responsibility of the author and do not represent the views of the World EBHC Day Steering Committee, Official Partners or Sponsors; nor does it imply endorsement by the aforementioned parties.
