If you've spent a large part of your career helping craft international agreements and then trying to hold the governments that have signed them accountable to their promises, you have likely become somewhat inured to disappointment. You give up expecting governments to walk the talk after the headlines fade about how they will save the world, at least without a lot of pushing. And you get depressingly familiar with watching needless death and illness go by due to lack of funding and political will.
Such has often been the case with respect to international promises to improve reproductive and sexual health, including maternal death and illness, long a largely neglected component of international public health efforts.
Now, however, in the wake of a study published in the Lancet that suggests maternal mortality may have fallen substantially since the early nineties comes a report that Ecuador, according to a report by Gonzalo Ortiz of InterPress News Service (IPS), has achieved a steep decline in maternal deaths and illness through a model program "centered on the mother's needs and not those of the doctor or midwife."
I've seen those words so many times in rhetorical statements and so rarely in practice that I just have to repeat them here: "centered on the mother's needs."
During the 1970s, the average annual maternal mortality rate in Ecuador was 188 per 100,000 live births. This fell to 142 in the 1980s, 75 in the 1990s and dropped again to an average of 55 maternal deaths per 100,000 live births for the period 2001-2007, according to IPS.
The fall in maternal mortality rates is being attributed to the Law of Free Maternity and Child Care, which was approved in 1994 and codified in 2006 to ensure a systematic approach to laws, policies and programs addressing maternal health in the country and to ensure financing for specific efforts to improve outcomes during pregnancy, childbirth, and in the weeks thereafter.
It is a program intended for even the poorest and hardest-to-reach communities where maternal mortality rates remain higher than the national average.
Poverty is endemic, for example, in Latacunga, about 35 miles south of Quito, the capital of the north-central province of Cotopaxi, one of the poorest in the country. Sixty-eight percent of the people live on less than two dollars a day, "a poverty rate 20 percentage points higher than the provincial average," according to IPS.
The principle behind Ecuador's law is simple. Every woman has the right to free, high-quality health care during pregnancy, childbirth and the postpartum period, as well as access to sexual and reproductive health programmes, says the first article [of the law].
The maternal health law gives communities both resources and the power to manage those resources for the best health outcomes.
Eulalia Salinas, the secretary of the Latacunga Users' Committee, tells IPS that training for these community groups and their supervisory responsibilities have been the key to success.
The law stipulates that a committee be created in each of the 221 cantons that are subdivisions of the country's 24 provinces. However, there are only 59 committees so far.
"Our committee was formed in 2004, through the work of the Women's Political Coordinating Body," said Salinas. This non-governmental organisation has fomented the creation of the committees, "which until then were dead letter, so that we could claim our rights," she said.
"We work on a voluntary basis to ensure that the budgeted funds sent to each canton are used for the free maternity programme, and that the women and children are treated to a high standard, and with human warmth," she added.
In Quito, Ecuador, Verónica Rocha, head of institutional development for the Free Maternity programme, told Ortiz that the law
"finances medicines, materials, vitamins and minerals, supplies and laboratory tests, for pregnant women, during labour and postnatally, as well as for children up to the age of five."
Integration and collabortion across departments is key. The achievements are a credit to "the entire public health system," Rocha said.
So is attention to the basic dignity and rights of women.
Community leaders note, for example, that the committees have successfully reduced mistreatment of women and discrimination with racist overtones at the hands of the very medical professionals meant to serve them.
"Before, the doctors would treat us badly. When we were giving birth they would shout, 'you dirty Indian, you opened your legs when you felt like it and now you're screaming! Shut up now!'" said Giovanna Álvarez, head of the Users' Committee in Saquisilí, Toaquiza's canton.
While the focus is on getting women to give birth in health centers rather than at home (where the majority of births now occur), it is also, at least in some communities, on "humanised childbirth."
Humanized childbirth. These words mean a great deal considering the extent to which women in labor in so many places are treated more like cattle than human beings.
Mothers can have a person of their choice with them during labour, they can have hot herbal tea before labour starts, and they can choose the birthing position they prefer.
"All these things are forbidden in other hospitals," reports IPS, "but in Saquisilí they were accepted after pressure from indigenous women, as a mark of respect for their traditional customs."
"Before, the doctor's convenience always came first. He would sit in front of the woman in labour, who was lying horizontally with her legs spread apart in metal stirrups, a completely unnatural position. The natural way is for the woman to be standing or squatting," so the baby is born with the help of gravity, Salinas said.
United Nations agencies now refer to Ecuador's law as a model for other Latin American countries, where deaths of women in childbirth and the postnatal period are either stationary or rising. The average maternal mortality rate in Latin America was 130 deaths per 100,000 live births in 2007. "International organisations and women's groups warn that this ratio is being reduced slowly or not at all," reports Ortiz.
I am sure it is not perfect; it clearly is not yet universal; I know there are bumps in the road. Yet it is refreshing, and worth celebration, to see that women in communities are being given the resources they know they need--and the power that is their right--to determine the best course of action in preventing other women from dying from pregnancy and childbirth.