**4. The Zika virus pandemic and pregnancy**

only in those cases to save the life of the mother—Paraguay and Guatemala [14, 15]. Brazil permits abortion to save the life of the mother, as well as in cases of rape and anencephaly [16]. In Panama, abortion can also be performed in cases of rape as well as fetal impairment or with parental authorization [17]. Five Latin American countries permit abortion to save a mother's life and preserve physical health—Argentina, Bolivia, Costa Rica, Ecuador, and Peru [3, 18, 19]). In addition to the aforementioned reasons, both Belize and Colombia permit abortion to preserve the mental health of the woman [20, 21]. Only one country in Latin America permits legal abortion—Colombia passed the legislation in 2012, and elective pregnancy ter-

**Figure 2.** Number of abortions performed in Latin America prior to the Zika epidemic, 1990–1994 and 2010–2014 [3].

However, criminalizing abortion in Latin American countries does not prevent abortion—similar to other regions of the world, unsafe abortions occur most frequently as a result of harsh regulations governing the access of girls and women to legal and safe termination of pregnancy [4]. During the period extending from 2010 to 2014 (and prior to the Zika virus outbreak), an estimated 6.5 million induced abortions occurred each year in Latin America and the Caribbean, up from 4.4 million during 1990–1994. As can been seen in **Figure 2**, the greatest number occurred in South America, where there were 4.6 million performed annually in 2010–2014. The annual rate of abortion was estimated at 44 procedures per 1000 women of reproductive age (15–44 years old). The Latin American abortion rate is approximately 48 for married women and 29 for unmarried women. Even prior to the introduction of Zika virus in this region, the proportion of pregnancies ending in abortion had increased between 1990–1994

In Latin American countries, all but one of which do not legally permit abortion on request, women will often seek the services of untrained or inadequately trained persons in dangerous and unsterile conditions or attempt to self-induce an abortion. Because of such circumstances, abortion mortality rates are up to 100 times higher in Latin America than in industrialized nations. For reasons that are obvious, there are scant published data available on who actually perform illegal abortions in Latin American countries. It must be remembered that not all illegal abortions are unsafe and not all unsafe abortions are illegal. Illegal abortions can be divided into those that are (1) performed clandestinely by medically qualified physicians in their medical offices or clinics; (2) performed by an individual, sometimes a physician but often by an abortionist who is medically unqualified, in an environment lacking the minimum medical standards, often termed "back alley," "back street," or "back yard" abortions; and (3)

mination in that country is now widely available [22].

**3. Who performs illegal abortions in Latin America?**

and 2010–2014, from 23 to 32% [3].

54 Family Planning

In 2015 the already desperate situation that pregnant girls and women in Latin American countries found themselves in when seeking to terminate a pregnancy was made worse by the introduction of a new emerging viral agent into Brazil, the Zika virus. This virus, previously identified only from Africa and Oceania, was new to the Western Hemisphere [29].

The initial recognition that a public health problem was occurring occurred on March 2, 2015, when the Brazilian authorities reported to the World Health Organization (WHO) that a large number of cases of an illness characterized by skin rash had been occurring in its northeastern states. The illness was initially identified from persons in Pernambuco in December 2014, after which there were more reports from Rio Grande do Norte, Maranhão, and Bahia in February and March 2015 (**Figure 3**). From February to April 2015, there were almost 7000 additional cases of illness characterized by skin rash reported from these states, but as Zika virus was not suspected, no tests were conducted for it. On April 29, 2015, the Bahia State Laboratory in Brazil reported to WHO that the Zika virus had been found in patient's samples, which was subsequently confirmed by polymerase chain reaction (PCR) testing at Brazil's National Reference Laboratory on May 7th. The same day, WHO and Pan American Health Organization (PAHO) issued an epidemiological alert that Zika virus infections were occurring in Brazil and, for the first time, in the Western Hemisphere. By July 2015, Brazil reported the association of Zika infection with neurological disease in adults—these included 49 cases of confirmed Guillain-Barré syndrome (GBS). In October 2015, Colombia announced that PCR-confirmed cases of Zika infection had been identified

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

57

It was on October 30, 2015, that the Brazilian authorities first reported an unexplained increase in the number of newborns with microcephaly. Soon after that announcement, a national public health emergency was declared as the number of suspected microcephaly cases continued to increase. Brazil announced on November 11th that there were 140 cases of newborns with suspected congenital microcephaly occurring in Pernambuco State alone and made world headlines by declaring a national public health emergency. The number of Brazilian infants with microcephaly suspected as being associated with Zika virus infections reached over 700 cases by mid-November 2015, and the virus was found in the amniotic fluid of two pregnant women. In response, both WHO and PAHO issued an epidemiological alert and requested that PAHO member states report increases of congenital microcephaly and other central nervous system malformations. On November 28, 2015, Brazil reported that Zika virus genomic material had been isolated from both tissue and blood specimens from an infant with congenital abnormalities, including microcephaly—the neonate had expired within minutes following delivery. Following this important report, both PAHO and WHO issued an alert to the association of ZIKV infection with neurological syndromes and congenital malformations in

**5. Governments respond to Zika virus, reproductive health, and** 

On November 17, 2015, the Pan American Health Organization (PAHO) issued an epidemiologic alert regarding Zika virus in Latin America [30]. As the Zika virus spread throughout Latin America in 2016 (**Figure 4**), the response of many Latin American governments to the threat of Zika virus infecting pregnant women, their unborn fetus, and the possible development of microcephaly was to recommend that women avoid or postpone their pregnancies. However, the restrictive abortion regulations that existed in these countries in the pre-Zika era remained intact. In Colombia and El Salvador, for example, women were cautioned by the Health Ministers of both countries to avoid becoming pregnant [31]. These recommendations provided a paradox, as greater than 50% of pregnancies in Colombia are unplanned, and El Salvador has the one of the highest rates of adolescent and teenage pregnancy in the region, with girls between the ages of 10 and 18 years representing approximately one-third of all pregnancies. In addition, sexual violence is prevalent in both countries. When the World Health Organization stated in June 2016 that women living in Latin American countries where Zika virus transmission was endemic should consider delaying becoming pregnant, the announcement affected millions of women living in 46 Latin American and Caribbean countries [32]. Unfortunately, in order to comply with these recommendations, reproductive-age girls and women would need to have access to family planning services and the corresponding education, which for the majority of impoverished women at risk for infection was either

in that country as well.

the Americas [6].

**pregnancy**

**Figure 3.** Map of Brazil. Zika virus infections and fetuses with microcephaly were first identified in Northeastern Brazil from the state of Pernambuco (10 on the map). Public Domain, https://commons.wikimedia.org/w/index. php?curid=1665180.

infections were occurring in Brazil and, for the first time, in the Western Hemisphere. By July 2015, Brazil reported the association of Zika infection with neurological disease in adults—these included 49 cases of confirmed Guillain-Barré syndrome (GBS). In October 2015, Colombia announced that PCR-confirmed cases of Zika infection had been identified in that country as well.

The initial recognition that a public health problem was occurring occurred on March 2, 2015, when the Brazilian authorities reported to the World Health Organization (WHO) that a large number of cases of an illness characterized by skin rash had been occurring in its northeastern states. The illness was initially identified from persons in Pernambuco in December 2014, after which there were more reports from Rio Grande do Norte, Maranhão, and Bahia in February and March 2015 (**Figure 3**). From February to April 2015, there were almost 7000 additional cases of illness characterized by skin rash reported from these states, but as Zika virus was not suspected, no tests were conducted for it. On April 29, 2015, the Bahia State Laboratory in Brazil reported to WHO that the Zika virus had been found in patient's samples, which was subsequently confirmed by polymerase chain reaction (PCR) testing at Brazil's National Reference Laboratory on May 7th. The same day, WHO and Pan American Health Organization (PAHO) issued an epidemiological alert that Zika virus

**Figure 3.** Map of Brazil. Zika virus infections and fetuses with microcephaly were first identified in Northeastern Brazil from the state of Pernambuco (10 on the map). Public Domain, https://commons.wikimedia.org/w/index.

php?curid=1665180.

56 Family Planning

It was on October 30, 2015, that the Brazilian authorities first reported an unexplained increase in the number of newborns with microcephaly. Soon after that announcement, a national public health emergency was declared as the number of suspected microcephaly cases continued to increase. Brazil announced on November 11th that there were 140 cases of newborns with suspected congenital microcephaly occurring in Pernambuco State alone and made world headlines by declaring a national public health emergency. The number of Brazilian infants with microcephaly suspected as being associated with Zika virus infections reached over 700 cases by mid-November 2015, and the virus was found in the amniotic fluid of two pregnant women. In response, both WHO and PAHO issued an epidemiological alert and requested that PAHO member states report increases of congenital microcephaly and other central nervous system malformations. On November 28, 2015, Brazil reported that Zika virus genomic material had been isolated from both tissue and blood specimens from an infant with congenital abnormalities, including microcephaly—the neonate had expired within minutes following delivery. Following this important report, both PAHO and WHO issued an alert to the association of ZIKV infection with neurological syndromes and congenital malformations in the Americas [6].
