Social inequality in sexual and reproductive health in Ecuador: an analysis of gaps by levels of provincial poverty 2009–2015

Abstract

Background Adequate access to sexual and reproductive health services is associated with better results. Analyzing the differences in access and outcomes of sexual and reproductive health (SRH) by share of poverty at the regional level makes it possible to measure the magnitude of the challenge of inequity. This paper aims to estimate the magnitude of health inequality in SRH in Ecuador for the period 2009–2015. Methods This study analyzed health inequalities in sexual and reproductive health indicators (obstetric and abortion complications, caesarean and home deliveries, adolescent fertility, and maternal mortality) for 2009 and 2015 comparing provinces in Ecuador. The absolute and relative gaps were estimated between provinces grouped by the percentage of individuals in multidimensional poverty; the slope index of inequality and the relative index of inequality were estimated as measures of gradient; and finally, the concentration index was also estimated. Results The analysis identified that obstetric complications, abortion complications, and cesareans have tended to increase from 2009 to 2015, without relevant differences between provinces ordered by poverty. Adolescent fertility decreased in the country as well as the inequality in its distribution among provinces: the CI was − 0.046 in 2015, down from − 0.084 in 2009. Home deliveries as a ratio of total deliveries have a decreasing trend with mixed results in terms of inequality: while there is a decrease in the absolute gap from − 211.06 to 184.4 between 2009 and 2015, the concentration index increased from − 0.331 to − 0.496. Finally, the maternal mortality rate increased in the period, also with greater inequality: from an absolute gap of − 39.30 in 2019, up to − 46.7 in 2015. In the same direction, the CI went from − 0.127 to − 0.174. Conclusions Ecuador faces major challenges in terms of both levels and inequalities in SRH outcomes and access to services. These inequalities related to poverty highlight the persistence of social inequities in the country. These health inequalities affect the wellbeing of Ecuadorian women but they are amendable. There is a need for pro-equity interventions, with stronger efforts in areas (provinces) with larger socioeconomic vulnerabilities.

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“…This WHO framework provides national information about equity regarding the utilization of essential health services between average coverage and full coverage and between rich and poor [39]. Research studies disaggregate the data based on gender [40,41], socioeconomic status [42][43][44][45][46], income [47][48][49], marital status [50], residence [51], ethnicity [52], and education [53,54]. This disaggregation facilitates the detection of inequity in health between advantaged and disadvantaged groups.…”

Poverty, Reproductive Health and Public Health Policies in Chile

“…The concept of health inequalities has been defined as "the differences that in health are not only unnecessary and avoidable, but also are considered unfair" [20][21][22][23] and, inequity is considered as any reducible difference or inequality, related to heterogeneous life conditions tied up with incomes differences, even when the poorest have equality of access to health services [21,24,25]. The perspective of social, cultural and political determinants of health has allowed to understand the mechanism underlying as substratum in the "causes of the causes" and in the routes or production processes of the inequities [22,26].…”

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“…There are four types of studies: First, those presenting inequalities in the performance outcomes of health systems in relation to efforts to ensure the right to health for vulnerable populations [ 4 , 5 , 17 ]. Second, studies highlighting efforts to ensure the right to health for specific disease conditions [ 10 , 12 , 20 , 24 ]. Third, papers analyzing the role of judicialization as a mechanism to ensure the right to health of populations and what it is currently playing across some of the countries in the region in this area [ 2 , 16 , 23 , 26 ].…”

“…Although evidence from Brazil points to stark inequalities for women of different socio-economic status, in Ecuador, one article points to nuanced effect that the evolution towards the realization of the right to health could have on equity [ 12 ]. Analyzed inequalities in sexual and reproductive health indicators in 2009 and 2015 across different provinces.…”

“…The authors found improvements in equity for indicators of adolescent fertility, and report on growing inequalities in home deliveries and maternal mortality between wealthy and poorer provinces. The authors found no significant changes in equity for indicators of obstetric and abortion complications and C-sections among provinces with greater percentages of population in poverty than wealthier provinces [ 12 ].…”