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

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 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.

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

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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

**Figure 4.** Active Zika virus transmission in the Western Hemisphere up to November 2016. Available from: https:// en.wikipedia.org/wiki/2015%E2%80%9316\_Zika\_virus\_epidemic.

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.
