The problem with Zika pregnancy advisories
SINCE NOVEMBER 2015, the Zika virus has been confirmed in the Caribbean in Barbados, Suriname, Guyana, Martinique, Haiti, Jamaica, Curaçao, the Dominican Republic, Haiti, French Guiana, Guadeloupe, Saint Martin, Suriname, the U.S. Virgin Islands, and Puerto Rico. By the start of February, it was declared a global emergency by the World Health Organisation.
Continuing our coverage of the Zika virus outbreak in Latin America and the Caribbean, we look at the impact and ramifications of the advisories against pregnancy, as the affected countries determine how best to approach this expanding health crisis. [tw-divider][/tw-divider]
Synopsis of the Zika problem
Zika first emerged in the Caribbean in 2014, having spread from Chile to Brazil and nearby countries, with increasing numbers of confirmed cases now being reported weekly. Most people who are infected have few or no symptoms, but those who do have signs and symptoms may experience muscle aches, fever, conjunctivitis, rash, headache, and joint pain.
Currently, the major feared complication of Zika infection is microcephaly, which causes brain underdevelopment and deformities for fetuses of infected mothers. Just this week, researchers in Brazil identified some of the clearest evidence to date of a direct link between the congenital disease and the mosquito-born virus.
Although the causal link is still officially undetermined, the gravity of the condition has led health organizations and their governments to advise women to delay pregnancy.
As it pertains to the severity of warnings against pregnancy, the World Health Organization recommends that “attention should be given to ensuring that women of childbearing age, and particularly pregnant women, should have the necessary information and materials to reduce risk of exposure.”
The Centers for Disease Control and Prevention has advised pregnant women, or those considering pregnancy, against traveling to countries with active Zika transmission. But in countries with confirmed cases, governments have issued their own specific warnings to their populations.
Brazil, Colombia, El Salvador, Ecuador, and Jamaica have explicitly advised all citizens of child-bearing age to avoid getting pregnant. So far, the advisories’ time period ranges from 6 months to 2 years. Colombia, for example, initially asked women not to get pregnant for the next 6 to 8 months, but that has now been increased to 2 years, while El Salvador unwaveringly recommends that women should delay pregnancies for the next 2 years. Jamaica’s government has similarly asked women to defer pregnancies for 6 to 12 months.
What the pregnancy advisories get wrong
“Certainly, the governments and health officials believe these advisories to be simple directives, and make them in good conscience. But the truth is that the advisories for women to delay getting pregnant are unreasonable, irresponsible, and dangerous”– Sherine Powerful, AMG Health Desk
As a recent Guardian editorial sums up: “It makes excellent sense for pregnant women to avoid putting themselves in danger of infection, but for women who are already in danger of infection to avoid pregnancy is an entirely different strategy, and it’s not going to work.”
The WHO recommendation is the only advisory, either official or unofficial, that directly acknowledges the fact that in order for women to take the necessary precautions against Zika, they must be provided with both the knowledge and the resources to do so. The other advisories neglect this. Instead, they treat the issue as though it is simply a matter of choice.
Pablo Kuri Morales, Deputy Minister for prevention and health promotion in Mexico, agrees: “You can tell people not to get pregnant, but that doesn’t mean they won’t.” It is common knowledge in the public health community that telling people not to do something, and thinking that everyone will adhere, is unrealistic. Relying on this alone is bad public health practice.
Additionally, the advisories unfairly place the brunt of the responsibility for managing the complications of Zika solely on one segment of the population — women. Yet the sexism that exists around the world make it such that women’s ability to exert agency and make choices for themselves are limited by patriarchy and politics.
The privilege of heeding advisories
Without a doubt, some women may find it easy to heed advisories against pregnancy. Perhaps, in spite of advisories, they are already mothers and had no intention of becoming pregnant in the short term. Others might be exclusively breastfeeding, which, for most, suppresses ovulation for the duration of nursing. Other women might have easy access to contraception or medical care, either within their country or across borders. And still, there are others who could determinedly and safely make the decision to abstain from sex.
These are only some of the factors and considerations that make it easier for people to avoid getting pregnant. But those that can pay attention to the warnings tend to have greater knowledge, privilege, and ability to do so.
For many other women, the choice is less certain. Some may want or need to have children now, because they run the risk of infertility if they defer pregnancy. Others still are under pressure from their partners and family to have children to continue the family line, and to ensure they will be taken care of in their old age. Others may experience reproductive coercion from a controlling partner and thus have little to no say in their getting pregnant.
It also needs to be mentioned that some pregnancies throughout the region result from sexual violence, such as incest or rape. These situations cannot be prevented simply by a person “choosing” not to get pregnant.
On the whole, in Latin America and the Caribbean 56% of pregnancies are unintended. Choice and agency are not a given for everyone.
Beyond what goes on within the individual and the family, there are external factors that make delaying pregnancy difficult when abstinence is not a realistic or desired option. Condoms, while increasingly widely available, are still inaccessible to those who cannot afford to purchase them or who live in areas far from places that distribute them for free. Additionally, contraceptive options are often limited or not an option due to availability, provider bias, contraindications, and personal or religious values.
Zika, as with many mosquito-borne diseases, disproportionately affects the poorest members of countries experiencing the outbreak, who do not have easy or full access to contraceptives or medical care. And most controversial of all these factors- the option to terminate a pregnancy is still taboo and illegal in many countries, with some exceptions.
Abortion in the Caribbean
In the Caribbean, terminating a pregnancy due to fetal impairment is only legal in the Bahamas, Barbados, Cuba, Guyana, and St. Vincent and the Grenadines. Only 2 of those countries have had cases of the Zika virus within the past several months, while there are still 13 other Caribbean countries that have recorded transmission.
In the Caribbean, 46% of abortions are unsafe. Because of these restrictions, and the fact that those who seek to terminate their pregnancies will often find the means to do so, the risk of people obtaining unsafe abortions is heightened due to the emergence of Zika and the ensuing advisories.
For women who are already pregnant and live in countries in which terminating a pregnancy is admissible if there is fetal abnormality, screening is an option. But screening is not widely available. And in many cases, definitive diagnoses of microcephaly cannot be made until around the 24th week of pregnancy, after which, for countries that do allow abortion, late-term abortions are not permissable. All of these factors together create the potential for dire consequences on maternal health.
Whose responsibility is it?[tw-divider][/tw-divider]“Yes, pregnancy happens in the body of an individual, but it is a social, cultural, and political experience shared and affected by families, community resources, societal values, and government policies. One cannot make an individual choice unless the policies and programs and support are in place to enable them to do so without limitation.” — Sherine Powerful, AMG Health Desk[tw-divider][/tw-divider]
Naivete is rife at the governmental and intergovernmental levels. Claudio Maierovitch, Director of the Department of Surveillance of Communicable Diseases at Brazil’s Health Ministry, has said that: “If she can wait, then she should”. Taken at face value, this suggests that not getting pregnant is a simple choice to make that rests solely in the hands of the woman.
The Pan American Health Organization has also gone on record to state that “any decision to defer pregnancy is an individual one between a woman, her partner and her healthcare provider.” But these statements could not be further from the truth for those who are most at risk for contracting Zika, yet do not have adequate means to delay pregnancy.
As Jessica Valenti, founder of Feministing argues: “The responsibility for caring for women potentially affected by Zika lies with governments – they’re the ones that need to ensure people have a full range of reproductive care. Governments also hold the responsibility to ensure that health warnings aren’t limited to women but given to men as well, calling on them to use condoms instead of simply insisting women not get pregnant.”
Uri Friedman of the Atlantic and Jose Miguel Guzman, former United Nations demographer and consultant for ICF International, add this to the conversation: “It’s not enough for governments to simply encourage women to put off pregnancy, as if fertility were solely discretionary: ‘Those women, those couples, have to have the possibility to do so. And for that they need … quick and good access to high-quality contraceptives and modern methods’…. ‘Calls to defer pregnancy are reductive unless they’re accompanied by an emphasis on women’s rights and needs… Without that emphasis, they’re also unlikely to be widely heeded’”.
What if we did defer pregnancy?
The Zika virus has now been declared a global emergency partly due to the fact that in Brazil, thousands of fetuses and newborns have been affected by microcephaly, potentially altering the course of the next generation if Zika continues to spread rapidly. But what would happen to populations in the region if no babies were born over the next two years?
If the Zika crisis were to last for up to 2 years, and pregnancies were put on hold for that period, naturally the population would fall, given the average fertility rate of 2.1 children per year needed to ensure a stable population. Among children, there would be a generation with much less people. Still, the population could easily bounce back if fertility rates returned to normal quickly after two years.
However, if the ZIK-V crisis lasted for longer than 2 years, and governments, the CDC, and the WHO urge people to continue to delay pregnancy, then Latin America and the Caribbean could begin to see drastic changes in their populations.
As we can see in the chart above, the World Fertility Report notes that many of the countries in the region are already below their replacement fertility rate. In this worst case scenario, populations would begin to age more quickly, meaning there would be more elders in the older generations than there would be individuals in the younger generations to take care of them. Additionally, some women might also be unable to conceive by the time it is deemed “safe” to get pregnant, further causing a shift in population dynamics from which countries might not be able to recover.
Time to be realistic and proactive
When it comes to preventing pregnancy, the availability and accessibility of external and internal condoms, the full range of contraceptive methods, and termination of pregnancy, are often controlled by powers outside of the individual.
Governments need to be realistic in what they are asking women to do, while also providing them with greater means to do so. The severity of this crisis should lead both governments and their citizens to responsible action.
Brazil, often a leader in the region, is already starting to reexamine its strict abortion laws. Governments should move to include comprehensive family planning in their considerations for dealing with the outbreak, but they must do so in tandem with supporting the needs of women who will become pregnant for as long as the Zika outbreak continues.