**6. The Zika pandemic has increased demand for abortion**

In the United States and other Western countries where abortions are legal, a number of women whose fetuses have shown evidence of congenital abnormalities as a result of Zika virus infection have chosen to undergo elective pregnancy terminations—subsequent evaluation revealed that the fetal brains had been damaged [34].

In Northeastern Brazil, which was both the epicenter for the Zika virus pandemic and had the highest rates of infection and greatest numbers of cases, the mostly impoverished girls and women in the region were frightened by the news of fetal malformations. Although many attempted to delay or avoid pregnancy, they were hampered by a lack of clear information about reproductive health and family planning, or it was difficult to access contraceptive methods. An investigation by the international nongovernmental organization Human Rights Watch found that the public health system in Brazil may not have been providing consistent and comprehensive reproductive health information to the girls and women in Northeastern Brazil [35]. Many told interviewers that during their prenatal appointments, they had not been informed of how to prevent Zika infection during pregnancy or that it could be transmitted sexually and thus were not using condoms even when they were available. As a result, they were resorting to clandestine (and frequently unsafe) methods to terminate their pregnancies. This was no surprise, as the illegality of abortion in Brazil had resulted in almost one-half million abortions in 2015, most of which were clandestine, just prior to the Zika outbreak [35]. Investigators from Human Rights Watch interviewed several women who stated they had witnessed or even experienced complication from unsafe abortions. Some physicians interviewed stated that they had personally treated girls and women who had terminated their pregnancies using caustic acid and other unsafe methods. Women related that, despite fearing that they had been exposed to Zika virus while pregnant, they had difficulty in obtaining the necessary diagnostic tests or ultrasonographic evaluation to determine if their pregnancies had been affected by Zika.

In 2016, Dr. Abigail R.A.Aiken from the University of Texas at Austin and her colleagues wanted to examine the effect that the Zika virus pandemic has had on requests for abortions from the endemic Latin American countries where the procedure was criminal [36]. To accomplish this, they collaborated with Women on Web (WoW)—a nonprofit online abortion help service based in the Netherlands. They offer an Internet-based portal through which women can request abortion medications—mifepristone and misoprostol. WoW has a small team of physicians who review requests from women desiring access to abortion medications outside the formal health-care setting through online telemedicine in countries where safe abortion is not universally available. If there are no medical contraindications identified, the doctor at WoW then authorizes a partner group in India to ship two drugs designed to induce abortion during early pregnancy to the woman's home [37–39]. The organization has offered free abortion medication for pregnant women with Zika virus [40]. Aiken and her colleagues analyzed the WoW data for all abortion requests from January 1, 2010 to March 2, 2016 in 19 Latin American countries affected by the Zika virus pandemic [36]. They compared these data to three countries where Zika was not expected to have an effect: Chile, Poland, and Uruguay. The sample was large— 28,670 requests for abortion were analyzed by employing a regression-discontinuity design to determine if requests for abortion increased after the Pan American Health Organization (PAHO) alert, as compared with preannouncement trends. During the final three study weeks, women were asked specifically if they were seeking an abortion because of concern about Zika virus infection. In their response, women did not confirm whether they had received a diagnosis of Zika infection. The results showed that in those countries with autochthonous Zika transmission, legally restricted abortion, and national public advisories to pregnant women, statistically significant increases of from 36 to 108% over baseline occurred for requests for

incompatible with religious and personal convictions or financially or geographically beyond reach. In addition, facilities in the most Zika-affected regions lack the capacity to respond to the increased demand for family planning [33]. This is due to inadequate infrastructure and delivery systems, insufficient commodities and supplies (including such medications as emergency contraceptives, long-acting reversible contraception, condoms, electric and/or manual and vacuum aspiration (MVA), and mifepristone and misoprostol), as well as a lack of trained personnel to provide quality care to meet the needs of the population. The deficiency in providing adequate contraceptive and safe abortion services, in combination with severely restrictive abortion laws in most countries where Zika was becoming endemic, forced many girls and women to consider, and eventually seek, clandestine and unsafe abortion methods.

**Figure 4.** Active Zika virus transmission in the Western Hemisphere up to November 2016. Available from: https://

In the United States and other Western countries where abortions are legal, a number of women whose fetuses have shown evidence of congenital abnormalities as a result of Zika virus infection have chosen to undergo elective pregnancy terminations—subsequent evalua-

**6. The Zika pandemic has increased demand for abortion**

tion revealed that the fetal brains had been damaged [34].

en.wikipedia.org/wiki/2015%E2%80%9316\_Zika\_virus\_epidemic.

58 Family Planning

abortion through WoW after the PAHO announcement [36]. The increased demand for abortion was most pronounced in Brazil (108% increase, p < 0.001), Ecuador (107.7% increase, p < 0.001), Venezuela (93.3% increase, p < 0.001), and Honduras (75.7% increase, p < 0.001). Increases in requests for abortion were also statistically found in Colombia (38.7% increase), Costa Rica (36.1% increase), and El Salvador (35.6% increase). In several countries where health advisories were not issued, the requests for abortions had increased but to a lesser degree. An exception to this was in Bolivia, with an approximately 68% increase demand. Abortion requests increased in Nicaragua, Panama, and Paraguay from 21 to 25% and Guatemala by more than 8% [36]. "It seems as though as though women were responding not only to the threat of Zika but to the advisories issued by their governments," said Dr. Aiken [37].

pandemic has caused several countries to rethink their reproductive health and education

Pregnant and Out of Options: The Quest for Abortion in Latin America Due to the Zika Virus…

http://dx.doi.org/10.5772/intechopen.72377

61

The situation of Zika virus infection during pregnancy, congenital infection, and malformation syndromes and abortion rights is not without precedent. Rubella is another virus causing congenital infection which, like the Zika virus, is a TORCH agent. TORCH is an acronym for those infectious agents which can cause congenital infections following vertical (motherto-fetus) transmission—**T**oxoplasmosis, **O**ther, **R**ubella, **C**ytomegalovirus, and **H**erpes) [29]. Between 1963 and 1965, rubella (also termed German measles) was epidemic in the United States. Similar to the Zika virus, pregnant women who became infected had relatively minor symptoms. However, the virus produced severe birth defects, and when maternal infection occurred during the first trimester, there was a 90% probability of passing the virus to the fetus [43]. The congenital rubella syndrome included microcephaly and brain damage, congenital heart disease, sensorineural deafness, ocular abnormalities, micrognathia, bone alterations, liver and spleen damage, and neurodevelopmental abnormalities. Miscarriage and stillbirth were also caused by the virus [44]. As the number of cases increased in the United States, the fear caused by the threat of having an infant with congenital rubella syndrome was not confined to any one ethnic or socioeconomic group—the virus could affect any nonimmune pregnant woman and her unborn child. During the epidemic there were approximately 20,000 surviving babies born with the congenital rubella syndrome, with many requiring intensive care or the possibility of lifetime institutionalization. During that time, abortion was illegal in the United States, but that did not stop women at risk for seeking terminations of their pregnancies. Approximately 11,250 pregnant women had miscarriages or, despite their illegality, therapeutic abortions during the epidemic. *Williams Obstetrics*, the standard obstetrical textbook at the time, recommended that abortion be performed in those cases of first trimester infection when the parents did not desire to assume responsibility of caring for an infant with congenital infection [45]. The rubella virus epidemic, and the public response to it, helped to facilitate the eventual 1973 US Supreme Court decision (Roe v Wade) that made abortion a fundamental right of a woman. Time will tell what effect, if any, that the Zika virus

policies, including those on the criminalization and restriction of abortion [16, 42].

pandemic will have on abortion rights in Latin American countries.

Address all correspondence to: davidalanschwartz@gmail.com

national Family Planning Perspectives. 1999;**25**(1):27-33

Medical College of Georgia, Augusta University, Augusta, Georgia, USA

[1] Eggleston E. Determinants of unintended pregnancy among women in Ecuador. Inter-

**Author details**

David A. Schwartz

**References**

Messages sent to WoW requesting abortifacients have reflected not only the strong feelings but also the desperation of the women at risk for Zika virus infection in these countries. From Venezuela, a woman wrote "I contracted Zika four days ago. I need an abortion. I love children, but I don't believe it is wise to keep a baby who will suffer. I don't know who to turn to – please help me" [41]. From the same country, WoW received this appeal—"We are going through a really serious situation for the economic and humanitarian crisis unleashed by Zika. There are no treatments, contraceptives nor pills to abort. I want to terminate my pregnancy but I cannot" [38]. A woman pleaded from Brazil "I need to do an abortion because of the great risk of infection with Zika here … Please help me. My economic situation is extremely difficult." And there is an entreaty from a women in Colombia—"Here Zika is a major problem and the health authorities do not help with it … I have no resources at this time and want to ask for your help because fear overwhelms me. What if the baby is born sick?" [38].

Amanda Klasing, a senior researcher with Human Rights Watch who specializes on women in Latin America, said "Regardless of the fact that you can go to jail for having an abortion in many of these countries, it's not surprising that women and girls would turn to clandestine avenues to procure abortions. Imagine how scary it must feel to be a girl or woman who becomes pregnant in a Zika-affected country right now" [39].
