Reproductive Health Matters

An international journal on sexual and reproductive health and rights

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Exploring women's needs in an Amazon region of

Ecuador

Isabel Goicolea

To cite this article: Isabel Goicolea (2001) Exploring women's needs in an Amazon region of
Ecuador, Reproductive Health Matters, 9:17, 193-202, DOI: 10.1016/S0968-8080(01)90024-2

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Exploring women’s needs in an Amazon
region of Ecuador
Isabel Goicolea

This study broadly explored women’s perceptions of their most pressing problems and needs in the
mostly rural Amazonian province of Orellana in Ecuador in mid-2000. In-depth interviews with
community women and health and social service providers used two rapid structured, qualitative
methods - free-listing and pile-sorting - to explore the ‘insider’s’ perspective, with the
participation of loco/ organisations, und generuted discussion on the emerging issues, giving an
opportunity for action aimed at improving women’s situation. Unequal gender relations,
subordination of women, economic problems, men drinking too much and domestic violence were
identified us the most pressing concerns. Several reproductive and sexual health problems were
also identified and information about others elicited. This paper describes the methodology used in
the research, reports on the 20 most cited problems and looks more closely at the findings in
relation to violence against women, lack of access to contraception and ambiguities arising from
the need to resort to clandestine abortion. Despite the existence of innovative national policies
related to domestic violence und reproductive health, there is a scarcity of resources and poor
infrastructure in Orellana. Patronising attitudes on the port of he&h service staff also greatly limit
women’s access to reproductive and sexual health services.

Keywords: gender issues, violence against women, family planning services, clandestine abortion,
research methodology, Ecuador

RELLANA was the last Amazonian prov- exploring community perceptions from an

0 ince of Ecuador to be created. With a

population of approximately 70,000 in
an area of 22,500 km,2 the region is a treasure
of biodiversity but it is also one of the poorest
provinces of the country. Orellana’s population
includes a combination of indigenous groups
living on communal land, engaged in subsist-
ence agriculture, and of peasants (mestizo),
who migrated in from other areas after the
arrival of the oil companies in the 1970s.
A study was undertaken in mid-2000 to
explore local women’s perceptions of their
problems, including reproductive and sexual
health problems. The study was motivated by
local community health workers’ organisations,
who wanted to do something about those prob-
lems. Because of the nature of the information
needed, qualitative methods were used for
insider’s perspective and in a participatory
manner. Although health and social service
providers were interviewed, special emphasis
was placed on the assessment of women’s
needs as felt by women themselves. The in-
creasing interest in rapid participatory tech-
niques that include qualitative methods reflects
a recognition of the usefulness of this type of
research. l-6
In the urban areas of Orellana, private for-
profit and non-profit clinics, public facilities
and pharmacies co-exist, whereas in rural
communities (where 70 per cent of the
population live) there is a scarcity of health
care resources. Health insurance coverage is
very low and access to health care and social
services is restricted by lack of transport, cost
and shortage of supplies and human resources:
‘A woman receiving treatment at the civil
hospital has to depend on several factors, and
especially on the “good luck factor” [laughs].
She has to depend on the good luck of the
surgeon being there, as well as the anaesthetist,
the necessary equipment.. . and also.. . the nec-
essay supplies to perform an emergency caes-
arean section. ’ (Ministry of Health doctor)
At the beginning of the1990s, awareness of the
need for better health care led to the creation of
two grassroots organisations of community
health workers (CHWs): the Fundacidn Salud
Amazdnica (for mestizo communities) and the
Asociacion Sandi Yura (for indigenous com-
munities). Their members include more than 300
voluntary CHWs who deliver primary health
care (PHC) to their communities. The study from
which this paper is drawn emerged from the
interest of these organisations in engaging in
work on sexual and reproductive health, an area
of health that has been relatively neglected in
research in this part of the country. It was
decided to explore local women’s needs initially,
to ensure that decisions on what action to take
were congruent with the women’s own priorities.
In addition to the CHW associations, there has
been a long tradition of popular education and
grassroots organisation in Orellana, including by
women’s, peasants’ and indigenous organisa-
tions. Many of these groups became actively
involved in the study and helped to make it
possible in a short period of time and without
much external support (only 30 per cent of the
total cost was covered from outside). The fact
that I was known to these organisations (having
previously worked for four years with Sandi
Yura) greatly facilitated this collaboration.
Methods
Through interviews data were gathered with a
purposive sample of community women and
service providers living and/or working in
Orellana. These included women from both
indigenous (13) and non-indigenous (12)
communities, of whom five were from urban
and 20 from rural areas. Four were single and
2 1 were married. Their ages ranged from 19 to
57, the majority being 25-35 years old. Eleven
had experience working in local organisations
while 14 did not.
194
Service providers were also interviewed,
with the objective of exploring differences
between their more ‘technical’ views and those
of the women. These were not exclusively
medical personnel since many women’s health
issues, including reproductive and sexual
health problems, are not dealt with in Orellana
by medical personnel7 Six were providers of
medical services from the public, private for-
profit and NGO sectors; seven were providers of
social services (activists against domestic
violence and social workers and policymakers
involved in this work); and two were nurses
working with local communities in health and
development issues.
All participants were informed that the study
aims were to understand women’s situation in
the area; we avoided mentioning reproductive
and sexual health directly so as not to
influence results. Confidentiality was assured
and participants were asked if they wanted to
participate. Permission to tape record the
interviews was also asked for. No compen-
sation was provided, but if during an interview
a woman referred to any reproductive or
general health problem affecting her, help was
offered. Participants were also assured that the
study results would be sent to them and to the
organisations working in the area, to contribute
to local knowledge and discussion of the issues.
(This has already been done.)
All the interview.s were conducted in
Spanish or Quichua, depending on the prefer-
ence of the interviewee. They were tape record-
ed and transcribed verbatim (a Quichua native
advised on translation of the interviews in
Quichua into Spanish). I was the only one
involved in the interview process, but I was
sometimes accompanied and introduced by
other women known to the participant.
During the interviews, structured, qualitative
methods were employed, including free-listing
and pile-sorting. Free-listing consists of asking
interviewees to list as many items as they can
think of in a particular domain.8 This method
has been used mainly for eliciting lists of
illnesses, e.g. with refugees in Sudan and with
Indian and Bangladeshi women; in each of
these studies, reproductive and sexual health
problems were commonly cited. lT2p5 Other
authors have utilised broader questions e.g. for
eliciting community problems.g

Pile-sorting has usually been employed in
combination with free-listing. To do this, items
obtained during free-listing are represented on
cards and participants are asked to sort these
cards into piles. In the research among Bangla-
deshi and Indian women mentioned above,
cards with pictures related to illnesses were
used,‘s2 and sexual health concerns were
explored in this way in other research among
men in Orissa, India.‘O
To avoid interpreting what the piles meant
to the women, we asked for explanations of the
groupings after each woman finishing the
sorting, which has been recommended by other
authors.” A record was kept of the themes by
which women ordered the cards and these were
used to elaborate a matrix showing the number
of times that two cards were placed together.
The more times two cards are grouped together
in the same pile, the stronger the conceptual
relationship between them is.” All the cards
were presented to each woman and the item on
each card was explained to them; they were
then asked to sort the cards into different piles,
however they wished. When asked how to do
this, we explained using Patel’s example of
sorting out the family’s washing.’
The full text of each interview was indexed
manually, while data from the free-listing and
pile-sorting were analysed using ANTHROPAC
3. 2 .i2 This software programme can compute
the frequency of each item and develop a ‘cog-
nitive map’ of similarities by presenting the
matrices according to spatial distances. This is
called ‘multi-dimensional scaling’ and ‘John-
son’s hierarchical clustering’. The more related
two items are in the participants’ minds, the
more times these will be grouped together in
the same pile. In the ‘cognitive map’ this is
reflected in shorter distances between these
items.”
Validity was assured by triangulation of the
qualitative data from the interviews with quan-
titative information from different sources, e.g.
health statistics and civil registry data, and by
informal discussions of preliminary data with
two social workers and a local woman.
The most important concerns are presented
here and three of the main themes closely
related to women’s reproductive and sexual
health needs, which emerged from the
interviews, are reported in more depth.
Reproductive Health Matters, Vol. 9, No. 17, May 2001
Results
After pilot testing the process with four
community women, it was decided to ask both
women and service providers to free-list all the
problems that women in the Orellana area
suffer from. Such a broad-ranging question
was selected to avoid asking specifically about
reproductive and sexual health problems, in
order to find out if these issues were relevant to
the women without directing their responses or
limiting them to already-named problems.13-15
During the free-listing, the women talked
openly and in-depth information was obtained
about the problems cited. However, prompting
and requests for explanations were also used
after the free-listing had been completed, to
elicit information1~2~8 about issues that had not
been mentioned spontaneously, such as
induced abortion.
Table 1 shows the total number of problems
mentioned in the free-listing. Table 2 shows the
20 problems cited most frequently and how
often thev were cited. Problems deriving from
gender inequity, including gender viilence,
featured prominently. Unlike what has been
found in other studies5 there were no great
differences between the problems cited by
providers and community women. This may
partly be due to the inclusion of providers of
social services along with medical staff.
Twenty community women participated in
the pile-sorting exercise, of whom 17 had not
participated in the free-listing. Eighteen of the
most frequently cited problems were repre-
sented in words and/or pictures on cards.
Topics such as unwanted pregnancy and
infertility were also included on the cards,
though they had not been listed previously.
Because many of the women, especially the
older and indigenous women, could not read
well. an effort was made to make the issues
understandable pictorially. For example, a
drawing of a drunken peasant man represented
‘Men drink too much’. Table 3 shows the
cognitive map obtained from the pile-sorting
exercise.
Table 1. Number of problems mentioned
Women Providers
Total problems mentioned __55 L- 56--
Total mentions 248 24
195
Goicolea

Table 2. Frequency of the 20 most cited problems, according to community women and health
serviceprovi’ders -
Women’s list (k25) Providers’ list (n=l5)
__ --- -__ ~~
Item listed % Item listed
Husband __~
beats wife . ~~ --~ 84 Husband beats wife ~~ .,
Men drink__-~too much 56 Economic problems
__
Economic ~~-problems 52
__ ~-Lack
___ information about sexuality
Husband _____~
humiliates wife 48 Husband humiliates wife
Husband controls money 44 Lack of education__-
~-__~ .~
infidelity 44 Dependence on__-__ husband
Gossip 40 Single
__-__mothers ~~~ __
Families have too many children 40 ‘Machismo’
___-- - ~~~ __
Jealousy/women’s
__ seclusion
~~~ __ 40 Lack of adequate__~~ family planning
__
Single mothers
__~~~__ __ 36 Reproductive tract infections
Menstrual -~--
problems 32 Infidelity
~~ -
Children’s
__- problems/diseases 32 Men drink too much
-__~ __ ~~ __
Lack of education 24 Excess work of women
-___
Diseases of ‘hidden parts’ 24 Lack
__ of access
~~. to__~~
health services__
Anaemia 20 Unwanted pregnancies
-__-~
Men go to brothels 20 Prostitution
-___-
Difficult to find job for 20 Husband’s domination
-__- __-~ __
Loneliness 20 Woman lacks leading roles
Separations 20 Teenage
- .__-~ pregnancies
‘Machismo’ 20 Pregnancy/delivery problems

Gender violence and machismo women’s economic dependence in exacerbating

Domestic violence was the most cited problem,
not a surprise given the high prevalence of this
problem in the province and the whole of Ecua-
dor.i6 Indeed, the cognitive map that emerged
from the interviews paints a picture in which
domestic violence is situated within the problem
of unequal gender relations, an issue described
across all of Latin America.‘7-20
‘Men who help at home are called “manda-
rinas” (those who are ordered around by a
woman). Others say why are you doing that,
that’s her work.. . They start criticising him., .
He has to stop doing those things to feel OK
with his friends and to avoid gossip.’ (Male
service provider)
This reflects what the first group of women
expressed during the free-listing: first, that
there is a strong association between physical
and psychological violence and that these are
closely related to alcohol abuse by women’s
partners: and second, the influence of com-
munity opinion, men’s sense of honour and
male violence.
‘If a woman had a boyfriend when she was
single, maybe they never had sexual relations,
but when she marries.. . her husband won’t
have known about this.. . but when he is drink-
ing with hisfriends, they tell him: your wife did
this and that.. .and here it comes - the
problem, the beatings.. . ’ (Service provider)
Morbidity and mortality data from Orellana
reflect differing gender roles; for men the
principal reasons for hospital admission in 1999
were injuries and gunshot wounds, while for
women they were normal delivery and
complications of abortion (Ministry of Health
Statistics 1999, Orellana Civil Registry Statis-
tics, 1999). Moreover, when women try to break
out of these gender roles, their men may not
accept it and violence may be the response.21
In sexual relations, men always have to con-
quer, to ask for ‘proof of love’ (sexual inter-
course), while a woman has to say no or risk
being labelled ‘bad’. Among the concerns men-

196
 Reproductive Health Matters, Vol. 9, No. 17, May 2001

Table 3. Multidimensional scaling of pile-sorting of community women’s problems (n=20)

I----_ Infertility -----\

0.981 _----
__-- \
/...................................
/..................................... --‘-..
..‘Y. \

I ,,/’ RTI , -.’

‘..* 1
I [ Menstrual problems ‘:x: ’\
I !.
f i.i. i.i. \
\ ......
/ I f..
f.. \
I i* \
Anaem ia \
\\ I
I
I .-..
Z.
‘..
‘.*
‘.* 1
‘.. I
: t
1

I I :..
Infidelity : I
I I \
____._..... -....--.---- ..___,_ \ j ’
I _/ ..__ I
\ Pregnancy and : I
\ delivery problems ij ,
\ .*.... .. .. .. . .. . .. . .. .. .
0.081 . ..*-- ,
\ .. .. . .. .. . .. .. .. .. . ..
\ Unwanted pregnancies I
I I
I I
I I
I I
I
Single mothers I
Jealousy I I
-0.37: ’ ...-..____ I I
-.-.___
-..____ / I
I ‘1\ ..-.._____
.. / Difficult to find work - I
I I
\ Husband ““,., I woman with children
\ I
\ controls j
\ money j /
\ ;.....-.
_..’ / /
\ _--
-0.821 \ -- .-
\\ i,, Gossip ,,j ,’ _---
’ - - - . ‘)._._._._._._.
1.’ /
‘k-_/C
---- ~-~~
-0.83 -0.41 O.bl 0.44 0.86

tioned high on both lists during the study, in- this violence when the perpetrator is drunk
fidelity, men going to prostitutes, jealousy and (‘Let him beat me, let him kill me, that’s why
separations were all included. The Spanish verb ’ he is my husband’) despite the work of many
cedar (to watch or protect) comprises a number local organisations.
of actions taken by men aimed at preventing The country has reacted to this problem by
wives and daughters from having contact with developing policies aimed at improving the
the outside world, which serves to confine them situation, for example a law passed against
within the narrow limits of their assigned violence against women and the family, and
gender role. the creation of women’s police stations (comi-
sarias de la mujer) to take charge of the man-
‘A jealous man wants his wife to talk with i
agement of reported cases.23 The Ministry of
nobody, sometimes, not to wear short clothes
Health (MoH) has developed guidelines for the
or stretch trousers, or to talk to friends.’
identification and management of domestic
(Community woman)
violence at health facilities,24 but good policies
Yet according to the women, the strongest do not always ensure their implementation. In
association is with alcohol abuse by men, ~ fact, MoH-run health services in Orellana
which has also been shown in larger studies.20-22 neither give out the necessary certificates of
Some of the interviewed women, especially evidence of violence [a requirement for legal
some of the indigenous women, still excuse action) nor are they sensitive to these problems.

197
Goicolea
The same can be said of lack of sensitivity on
the part of provincial government and the
police. The need for greater awareness-raising
among women on their rights is no excuse for
passivity on the part of service providers. Yet
Orellana has only a small office offering legal
advice to women experiencing domestic
violence, run by a group of local women on a
voluntary basis, who are also advocating the
establishment of an official comisaria de la
mujer in Orellana.
Contraception: a right or a duty?
The gap between the family planning needs of
Orellana women and the services available to
them shows that national policies are not being
implemented. Thus, although the Constitution
establishes the right of citizens to decide on the
number of children they have,23 and the MoH
has published comprehensive protocols for
delivering family planning services, including
emergency contraception,24 access is greatly
restricted in Orellana. Provision is erratic and
concentrated in the bigger urban areas and the
principles of quality of care (technical compe-
tence, communication skills, variety and con-
tinuity of methods) are seldom firlf31ed.25
Poor accessibility may be one of the reasons
for the high fertility rate in Orellana (around 5.5
for the Amazon basin) and low modern
contraceptive use.26Or do women (or men) want
to have a lot of children? Although the free-
listing did not provide a clear answer, ‘having
too many children’ was cited as a problem by
several participants, though less frequently than
others. Other points that emerged from the
interviews also implied that many pregnancies
were not welcome, e.g. the frequent resort to
remedies with supposed abortifacient effect.
Being a single mother was also cited as a
serious problem, while being childless, though
seldom alluded to, was also felt to be a prob-
lem. The use of traditional methods of fertility
control was frequently cited, along with
comments about the difficulties of bringing up
a lot of children:
‘Now the problem of having many children is
really felt, because of.. . the current crisis.. .
money doesn’t stretch, especially for young
couples. ’ (Community woman)
198
A national study has also found high rates of
unwanted and mis-timed pregnancies in Ecua-
dor.27 Poor access to modem contraceptive
methods and lack of accurate information com-
bined with fears of using these methods to con-
trol a natural process help to explain the mis-
match between women’s desires and the number
of children they have. Many of Orellana’s health
service providers also have a negative way of
presenting family planning:
‘At the hospital they told her that it was her
fault that she had a malnourished child, and
that if she didn’t know how to look after her
children why didn’t she “take care of her-
self “. . . they told her to talk to the midwife,
who would tell her how to “take care of
herself”. ’ (Community woman)
Thus, contraceptive use may be presented more
as a duty than as a right, and the provision of
contraception a top-down affair in which pro-
viders tell women what to do instead of sup-
porting women and men to select the method
that best suits them. Moreover, the burden of
family planning has been placed on women,
while men usually adopt an irresolute role,
sometimes blaming women if pregnancy occurs
or opposing birth control as ‘women’s libera-
tion’ and therefore objecting to women using a
method at all.
Thus, in addition to improving access to
contraceptive methods, efforts should be made
to change the approach to contraceptive pro-
vision. Patronising attitudes of providers
should be challenged to transform family
planning services into a way for women and
men to exercise their right to control their
fertility.
Abortion: the silenced reality
In contrast to other areas where Ecuador has
made a lot of progress, the problem of danger-
ous abortions remains unchallenged. Abortion
is still prohibited under the national Penal Code
and subject to imprisonment except when the
woman’s life is in danger or when the preg-
nancy results from the rape of a mentally dis-
abled woman and even then, permission of the
woman’s guardian is needed.23 This stringent
law contrasts with real life, where induced
abortion is very frequent.2*

In Orellana, complications of abortion were
the second most frequent cause of hospital
admission for women, accounting for 13.5 per
cent of all admissions among women of fertile
age (Ministry of Health Statistics 1999).
Although none of these abortions is reported as
induced, local health personnel said that most
of the admissions were for complications of
procedures carried out ‘somewhere else’.
Although abortion did not come up during the
free-listing exercise with the women, when asked
about it, several participants said induced abor-
tion was quite common. Oxytocin, high-dose
hormonal contraceptives, chloroquine and pesti-
cides, alongside dilatation and curettage (D&C) in
some private clinics, were all cited, and all have
been reported in other Latin American countries
too.28-30And despite the fact that the only drugs
with proven effect for inducing abortion (mife-
pristone with misoprostol) are not available in
Ecuador, pharmacists recommend and sell a
number of drugs over the counter thought to act
as abortifacients.
Abortion was the most important problem
for women cited by one of the private prac-
titioners interviewed, and all the other providers
interviewed agreed that induced abortion was
very common, especially in private practice.
‘Generally, the great majority of adolescent
girls ty to induce abortions.. . at whatever cost
and by whatever means, it doesn’t matter how. ’
(Private doctor)
The fact that abortion is so common and
information about ‘remedies’ so widespread
contrasts with its absence during the free-
listing, where the women did not include it as a
problem, though providers did include un-
wanted pregnancy. Moreover, this contrasts
with the fact that the women talked about
abortion very openly when asked about it, and
without euphemisms. Yet they always alluded
to abortion as a problem for ‘other women’.
Many participants said they knew someone who
had had an abortion, but none said she herself
had had one. This suggests conflicting feelings
between what ‘ideal’ women are supposed to do
(endure their destiny, including unwanted
pregnancy) and what women actually do. Given
these conflicts, no matter what women decide to
do about unwanted pregnancy, the outcome
may not contribute to self-esteem.
Reproductive Health Matters, Vol. 9, No. 17, May 2001
In Orellana, and in Ecuador in general,
advocacy for the legalisation of abortion or
improvements in abortion care has not been a
strong movement. Orellana women’s groups
have been active in mobilising against do-
mestic violence and criticising the poor access
to health care for women, but abortion has
seldom been raised. During the interviews,
abortion did not emerge as a woman’s right
but as something inevitable, even if un-
acceptable. Finally, although private, for-
profit practitioners are performing many
abortions and making money that way, the
public health services may also have punitive
attitudes.
‘When she is under the influence of the anaes-
thetic we ask her again, and then she tells us
that she has taken some pills or an injection,
and she begins crying.. . then we ty to calm her
down but slowly, slowly.. . in order to teach her
not to do it again.’ (Ministry of Health nurse)
The issue of abortion in Orellana reflects the
contradiction between real life and imposed
paradigms, the conflict between what women
have always done and what has been sanc-
tioned as good somewhere far from the reality
of the women’s lives. Discussion by women and
providers about the issue is a must, to expose
inaccurate and potentially harmful infor-
mation, i.e. that the use of drugs can be
dangerous and to avoid self-blame and other
negative attitudes.
Discussion
Qualitative research has the potential to create
a rapport between researcher and community
members and to support participation and
empowerment, as in the case of the rapid
appraisal procedures used in this study, where
research is understood as the first step for
action.31
The methodologies employed in this study
allowed us to obtain a general picture in a short
space of time, with little money or need for
experts, but with the active participation of
local organisations and a focus on women as
active protagonists in an effort to learn what
would be useful to better meet their needs.
We did not explore men’s views nor
whether there were differences between
Goicolea

indigenous and mestizo women’s needs, or the ‘In the beginning my husband didn’t under-
specific needs of adolescents. Qualitative stand.. . he wanted me to have babies.. . maybe
research such as this cannot quantify the because of jealousy... he was machista, he
magnitude of the problems, and in the case of didn’t want to send me to the church workshops
Orellana, where quantitative data are lacking, but I wasprm and slowly I taught him.. . Then
a larger study should be done in order to the FUSA health programme began.. . they were
obtain more information. looking for CHWs and the whole community
The women of Orellana are a group whose selected the two of us.. . CHW workshops
voices are not usually taken into account. helped him.. . he began to understand and he
Qualitative methods enabled them to talk and began to change... he left behind his
seemed ‘natural’ to them (with the exception of machismo . . . and I also became braver, stronger. ’
the free-listing, which needed explanation). (Woman community health worker, 22)
The broad-based question about problems in
general made analysis more difficult, because Problems of reproductive and sexual health
and of sexual relations were among the most
many times the ‘problem’ listed was not one
important concerns for both women and health
word but a short sentence, but it avoided
and social service providers in Orellana. Given
narrowing women’s options to provide their
the broader economic and gender-related con-
own answers.
text in which these issues are situated,33 a
The extent of community participation was
comprehensive approach is called for that takes
limited because of time constraints. Further
into account not only women’s health-related
discussion on the issues that emerged (such as
needs but also their reproductive and sexua.1
machismo, access to services and domestic vio-
rights. The combination of qualitative research
lence) did take place, including how each
oganisation should contribute to improvement methods used in this study has helped to
identify in a participatory manner how these
in the situation. Steps for action are being
matters are perceived in Orellana.
developed by many of the groups that were
involved in the research, and a Health Com-
Acknowledgements
mittee in charge of improving the collaboration
This study is based on the dissertation ‘Situat-
between health and social services in relation
to women’s issues, has been created. In fact, the ional Analysis of Reproductive and Sexual Health
in Orellana’, presented in September 2000 in
increasing interest in reproductive and sexual
partial fulJlment of an MSc in Reproductive and
health and women’s well-being offers an
Sexual Health Research, London School of Hy-
opportunity for improving access to health and
giene and Tropical Medicine, UK. It was sup-
social services, not only supplies and infra-
ported by Medicus Mundi Guipuzcoa in Spain
structure but also staff attitudes. The country
has adequate policies and protocols and, if and the Fundacidn Salud Amazdnica, Sandi Yura
and the church of Aguarico in Ecuador.
implemented, this situation should improve
dramatically.
Correspondence
This study has highlighted the fact that
Isabel Goicolea, C/Abendario 13 l”C, 01008
women saw gender inequities and their conse-
Vito& (Alava), Spain. E-mail: isagoicolea@
quences as a main worry. The fact that in such
yahoo.es
an impoverished area women perceived gender-
related problems32 as central and relevant may
be due to the work of local women’s organisa-
tions in the past ten years and more. However,
parallel work with community groups led by
men (peasant organisations, the church, indige-
nous CHWs) has not been strong, and the male-
macho role has yet to be challenged. Popular
education initiatives and grassroots oganisation
represent an opportunity, and the evidence is
that this is feasible:

200

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201
Goicolea
Riisumk
Cette etude a examine comment les femmes
percevaient leurs problemes et besoins les plus
pressants a la moitie de 2000 a Orellana, pro-
vince amazonienne rurale de 1’Equateur. Des
entretiens avec des femmes et des prestataires
de services sociaux et de sank ont utilise deux
m&odes qualitatives rapides et structurees -
l’etablissement non dirige de listes et le classe-
ment des themes par piles - pour etudier la
perspective ti de l’interieur n avec la participa-
tion d’organisations locales; ils ont suscite des
debats sur les questions emergentes, donnant
l’occasion d’agir pour ameliorer la situation des
femmes. L’intgalite entre les sexes, la subordi-
nation des femmes, les problemes economiques,
les exces de boisson des hommes et la violence
dans la famille ont CtP identifies comme les
difficult& les plus urgentes. Plusieurs pro-
blemes de Sante genesique ont egalement et6
cites et des renseignements sur d’autres
problemes ont ete obtenus. L’article d&it la
methodologie utilisee et les indications sur les
20 problemes les plus frequemment cites; il
Ctudie plus en detail les donnees sur la violence
a l’egard des femmes, le manque d’acces a la
contraception et les ambigu’itb naissant de
l’obligation d’avoir recours a l’avortement
clandestin. Malgre l’existence de politiques
nationales novatrices sur la violence dans la
famille et la Sante genesique, la province
d’orellana manque de ressources et ses
infrastructures sont mediocres. L’attitude
condescendante du personnel de Sante limite
aussi I’acces des femmes aux services de Sante
genesique.
Resumen
En esta investigation realizada a mediados de1
an0 2000 en la provincia rural Orellana, en la
amazonia ecuatoriana, se exploraron las per-
cepciones de las mujeres de sus problemas y
necesidades mas apremiantes. En las entre-
vistas a profundidad con mujeres de la comuni-
dad y con proveedores de servicios sociales y
de salud, se usaron dos metodos cualitativos de
estructura rapida - el listado libre (free-listing)
y la clasificacion por pilas (pile sorting) - para
explorar la perspectiva “desde adentro” con la
participation de organizaciones locales y gene-
rar discusidn acerca de temas emergentes, dando
oportunidades para acciones dirigidas a
mejorar la situation de la mujer. Las relaciones
de genera desiguales, la subordination de la
mujer, el consume excesivo de alcohol de parte
de 10s hombres, y la violencia domestica fueron
identificados coma las preocupaciones mas
apremiantes. Se identificaron ademas varios
problemas de salud reproductiva y sexual, y se
obtuvo information acerca de otros. Este
articulo describe la metodologia usada en la
investigation e informa sobre 10s 20 problemas
m&s citados. Se enfoca en mas detalle en 10s
resultados relacionados con la violencia en
contra de la mujer, la falta de acceso a anti-
conceptivos, y las ambigtiedades surgidas de la
necesidad de recurrir al abort0 clandestine. A
pesar de la existencia de politicas nacionales
innovadoras relacionadas con la violencia
domestica y la salud reproductiva, 10s recursos
en Orellana son escasos y la infraestructura
pobre. Las attitudes condescendientes de parte
de1 personal de 10s servicios de salud limitan
ademas el acceso de las mujeres a 10s servicios
de salud sexual y reproductiva.