According to the 2010 census, Ecuador has 14,483,499 inhabitants, the majority of whom define themselves as mestizo, or of mixed race (71.9%), and the rest as Montubio (7.4%), Afro-Ecuadorian (7.2%), indigenous (7.4%) or white (6.1%).
The province of Sucumbíos, where the experience took place, is situated in north-eastern Ecuador in the Amazonas region. It has a population of 176,472 inhabitants, of whom 13.4 per cent are indigenous, for the most part Kichwa. In Ecuador, 52% of women are of child-bearing age. While the national average of live births per woman is 1.8, in Sucumbíos it is 2.4.
In January 2007, Ecuador embarked on a political process known as the Revolución Ciudadana (Citizen’s Revolution). The process’s most significant achievements so far include the approval of the new Constitution, the State’s recovery of its national planning role and the establishment of the National Plan for Sumak Kawsay, or Good Life, which has twelve national objectives. The experience described in this paper is related to Objective 3: Improve the population’s quality of life.
Sucumbíos is home to FONAKISE, an indigenous organisation founded in 1978 that encompasses 58 Kichwa indigenous communities. The organisation is recognised as one of the province’s major health players. It has cooperation agreements with the Sucumbíos Provincial Health Directorate, and it enjoys the backing and credibility of grassroots communities. Its socio-organisational structure comprises associations of traditional health promoters, women, young people and birth attendants that are active at various levels of project implementation. Between 1994 and 2003, FONAKISE implemented comprehensive health projects with the support of the Swiss Red Cross; since 2003 it has received support from RIOS.
In 2008, the Ministry of Health (MoH) started implementing the National Plan for Rapid Reductions in Maternal and Neonatal Mortality. The Plan incorporates the WHO-PAHO definition, according to which maternal death is “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes".
Maternal death and adolescent pregnancy in Ecuador
Despite the efforts made in recent years, maternal death continues to be a nationwide problem in Ecuador, especially among poor and indigenous women living in rural parts of the country.
Maternal mortality rate: Changes in the number of maternal deaths for every 100,000 live births between 2005 and 2009 demonstrate how serious the problem is: the number of deaths rose from 73 in 2006 to 96 in 2009. (National Statistics and Census Institute, INEC, 2009)The Maternal Mortality Reduction Plan implemented since 2005 served to structure the National Plan for Rapid Reductions in Maternal and Neonatal Mortality launched in 2008 and currently being implemented. Thanks to the latter’s implementation, underreported data were incorporated into the statistics.
Causes, age range and cases of maternal death: According to MoH data, between 2002 and 2006 the main cause of maternal death was haemorrhages (38% of cases), followed by hypertension and eclampsia (26%) and sepsis (21%). Women between the ages of 20 and 24 were the group most seriously affected (25%). During the same years, there were 170 cases of maternal death caused by: delay at the hospital (82%); delay in the transfer (or 8%); delay in the home (5%). There is no data on the remaining 5%.
With regard to adolescent pregnancy, in Ecuador more than 20% of women became mothers or were pregnant while adolescents. (Demographic and Maternal and Child Health Survey, ENDEMAIN, 2004) In addition, among families of low socio-economic status, 30% of adolescents experienced their first sexual encounter at 16 or younger; that figures falls to 19% among families of middle socio-economic status and to 12% among families of high socio-economic status. In addition, 89% of adolescents who had sexual relations before the age of 17 did not use a condom during their first encounter.
The challenges
The first challenge for the indigenous organisation FONAKISE and for the Provincial Health Directorate was to implement the National Plan for Rapid Reductions in Maternal and Neonatal Mortality in widely dispersed indigenous rain forest communities.
It is common knowledge that in all the world’s societies, but especially and more consistently in indigenous communities, there is a barrier to talking about sexual matters. However, no plan to reduce maternal mortality can be carried out without broaching the matter, without trying to overcome the reluctance to talk about sexuality. Trying to understand the taboos, grasp what they mean and enhance understanding of them was a second and no less important challenge.
The third challenge was to adapt the premises of the National Plan to the indigenous way of thinking with a view to its implementation.
Some key considerations
We believe it is important, in order to further understanding of the experience, to set out some of the key considerations underpinning implementation of the National Plan in the communities.
- There is a long tradition of cooperation between FONAKISE, the Sucumbíos Provincial Health Directorate and RIOS. For over 14 years, the three have together implemented various programmes, especially in the context of primary health care. They have built up a relationship of mutual trust.
- In this context, this is one of the pioneering experiences linking the Western medical system with the indigenous medical system. Using the fact that they interacted in the daily lives of the communities as a starting point, the two systems sought intercultural health strategies to overcome barriers that were mainly cultural in nature.
- In 2000, FONAKISE (with broad participation by its women’s groups) and the Provincial Health Directorate adapted UNICEF’s ‘Facts for Life’ to Kichwa reality. The text is in its second edition, and continues to this day to be used to train large groups of indigenous men and women. The result of that exercise was that the organisations agreed to include the following subjects: risk-free maternity, family planning and AIDS. By broaching those subjects in the communities, it became possible to bring to light the relevant problems and to open doors with regard to sexual and reproductive health and the participation of specialised institutions such as the United Nations Population Fund (UNFPA) and UN Women.
- Thanks to the high level of trust, a baseline survey on sexual and reproductive health was launched with the communities in 2008, the results of which are of great interest and provide guidance for the implementation of the National Plan for Rapid Reductions in Maternal and Neonatal Mortality.
Principal baseline findings in relation to maternal mortality
The results of the baseline survey enhanced understanding of the issue not only among public health servants but also among the indigenous people themselves and their health service providers. The principal findings include the following:
- With regard to the causes of maternal death during labour, the cause most often cited by the indigenous is “heavy bleeding” (23.6%); this coincides with the main cause of maternal death established by the Health Ministry, namely “haemorrhaging”. “The placenta doesn’t come down” (17.6%) and “lack of transportation” (13.6%) were cited second and third, respectively. The fact that shamanism is cited by 9.6%, or that a pregnant woman ate “food stuck to the pan” (belief that if a pregnant woman eats of the rice stuck to the side of the pan, which is difficult to take out, it will be “similarly” difficult to take out the child), is indicative of indigenous beliefs and of the notion that the Plan “is only from outsiders”.
- With regard to the reasons why the community’s women miscarry, 34.47% blame miscarriages on “falls”, 32.2% on “domestic ill-treatment”, and 11.87 per cent, again, on shamanism. These perceptions provide a good basis for the formulation of training and action strategies.
- When it comes to whom women trust for assistance while in labour, a resounding 55.8% place their birth attendants in first place, followed by a substantial 28.2% who mention Health Ministry personnel. These perceptions tell us with whom we will have to work.
- With regard to where women prefer to give birth, “home”, cited by 60.5%, comes first, followed by the hospital, for 20.9%. This tells us where we have to work.
- When it comes to why women choose to give birth at home, tradition came first, at 38 per cent, and family support second, at 27%; poverty or lack of money came third, at 19 per cent.
- Lastly, and with regard to the position for childbirth, 62% prefer to kneel, i.e. to be upright, and 31% to be on their backs, or lying down.
Implementation of the National Plan for Rapid Reductions in Maternal and Neonatal Mortality
The Plan was implemented in several stages, as set out below.
Adapt the Plan to the organisation’s proven strategies and methods, which signified: use the organisation’s strength and its relationship with the Provincial Health Directorate to initiate a process of empowerment based on the organisation’s capacity for technical and financial management; strengthening of women’s organisations so that they were able to implement the Plan; training and participation of indigenous health service providers (traditional birth attendants, health promoters, indigenous youth and communities); coordination and formulation of action plans among Provincial Health Directorate technicians, the Directorate’s Intercultural Health Department, FONAKISE and non-governmental and intergovernmental organisations (RIOS, UNFPA and UN Women).
Incorporate the Plan into the official Model for Integrated Health Care with a Family, Community and Intercultural Approach (Modelo de Atención Integral de Salud con Enfoque Familiar Comunitario e Intercultural, or MAIS FCI), especially in the area of primary health care, which signified: outreach activities in the communities, focusing the Plan on activities to promote health and prevent maternal deaths; introducing the Community Obstetric Emergency Plan and tackling the four delays; participation of indigenous youth groups and training in various fields and at various levels.
Establish mechanisms with an intercultural approach in the Plan, in view of the baseline findings, respect for and use of indigenous knowledge and implementation of culturally appropriate birth houses. Improve the information, communication and systematisation system, use of talking maps and implementation of a referral and counter-referral system and of networks of community obstetric care.
Results
Since the 2008 launch of the National Plan for Rapid Reductions in Maternal and Neonatal Mortality, and with a view to achieving the national goal of reducing maternal mortality to 35% by 2013, the following results have been achieved:
- The National Plan for Rapid Reductions in Maternal and Neonatal Mortality has successfully been introduced in the Kichwa indigenous communities of Sucumbíos.
- Informed access to methods of contraception has increased.
- Obstetric care networks have been established.
- Educational, communication and training activities have been carried out using an intercultural approach.
- A subsystem has been implemented for surveillance and epidemiological investigation of maternal death.
Contribution to the national goal of increasing the number of births in institutions by 70 per cent
The Association of Traditional Kichwa Birth Attendants (Asociación de Parteras Tradicionales Kichwas, or APTK) has been set up. It is made up of 40 community birth attendants trained and accredited by the Sucumbíos Provincial Health Directorate. At present the birth attendants are able to identify the Four Delays; they support the community epidemiological process, identify danger signs, act as a first level of referral and counter-referral and carry out activities to monitor pregnancies and deliveries in their communities and in the culturally appropriate birth houses. Since 2008 the Sucumbíos Provincial Health Directorate has opened five culturally appropriate birth rooms, in which there have been 1,071 deliveries, most of them in the upright position.
Under the leadership of the Association of Kichwa Women of Sucumbíos (Asociación de Mujeres de la Nacionalidad Kichwa de Sucumbíos – Ecuador, or AMNKISE), the Plan for Reproductive and Sexual Health Training was launched. The plan was implemented in an average of 55 communities per year, training families (4,249 people in all) in subjects pertaining to maternal mortality, reproductive and sexual health and domestic violence.
Contribution to decreasing the number of adolescent pregnancies
The Association of Young Kichwa People of Sucumbíos Ecuador (Asociación de Jóvenes de Nacionalidad Kichwa de Sucumbíos Ecuador – AJNAKISE) was set up. The Association focused on reproductive and sexual rights to draw up the Plan for Information, Education and Communication on Adolescent Pregnancy. The “Join in Circuit” approach was used to work with twenty indigenous secondary schools with the participation of 3,243 students. In addition, 150 radio programmes were broadcast in the Kichwa language. At present, the National Intersectoral Strategy for Family Planning and Action on Early Pregnancy (Estrategia Nacional Intersectorial de Planificación Familiar e Intervención de Embarazo Temprano – ENIPLA) is being implemented. The aim is to have an impact on the Services for Special Care for Adolescents and to ensure access to family planning methods.
Contribution to improved access to sexual and reproductive health services
Under the leadership of the Provincial Health Directorate, the problem-solving capacity of health personnel was strengthened with a focus on intercultural concerns and sexual and reproductive health rights. Twenty operational units and 66 professionals are taking part in the Community Emergency Plans covering 55 indigenous communities.
Conclusions
The experience described here is an on-going process in which coordination between the indigenous organisation and the State health sector is the most crucial element. Our conclusions are as follows:
- the baseline served to focus the work in terms of its intercultural aspects, reinforced the participation of traditional agents, especially birth attendants, and heightened awareness among health professionals;
- the positioning of the reproductive and sexual health programme was a key factor of action with a rights-, gender- and generation-based approach, promoting the State’s health services;
- the work of the women’s organisation served to heighten community awareness of health issues;
- the accreditation of traditional agents allowed them to obtain official State recognition;
- the establishment of the Community Obstetric Emergency Committees paved the way for adequate problem-solving training in the communities and among health personnel;
- as a result of the joint work, there were no maternal deaths among indigenous women this year (January - October 2012).
* Ms. Elizabeth Moreno, Staff member of the Sucumbíos Provincial Health Directorate
Dr. Nathalie López, Project coordinator, RIOS Ecuador
