Women's Reproductive Intentions and Behaviors during the Zika Epidemic in Brazil

"I found out about Zika virus after she was born." Women's experiences of risk communication during the Zika virus epidemic in Brazil, Colombia, and Puerto Rico

Providing accurate, evidence-based information to women with Zika infection during pregnancy was problematic because of the high degree of uncertainty in the diagnosis of the infection and the associated risk. The 2015-17 Zika virus epidemic overwhelmingly affected women in countries with limited access to safe abortion. Understanding women's perspectives on risk communication during pregnancy in the context of an emerging pathogen can help inform risk communication in response to future outbreaks that affect fetal or child development. We conducted a cross-sectional qualitative interview study with 73 women from 7 locations in Brazil, Colombia, and Puerto Rico to understand women's experiences of Zika virus (ZIKV) test and outcome-related communication during the ZIKV pandemic. We used thematic analysis to analyze the in-depth interviews. Participants in Brazil and Colombia reported that the healthcare system's lack of preparation and organization in communicating ZIKV test results and associated adverse outcomes led to their feeling abandoned and alone in confronting the challenges of a ZIKV-affected pregnancy. In contrast, participants in Puerto Rico reported that the regular testing schedules and clear, well-planned communication between the care team and between providers and pregnant women helped them to feel they could prepare for a ZIKV-affected pregnancy. Communication of the risk associated with an emerging pathogen suspected to affect pregnancy and developmental outcomes is a fraught issue. Public health authorities and healthcare providers should work together in the interpandemic period to understand families' preferences for risk communication during pregnancy in the presence of uncertainty and develop a community-informed plan for risk communication.

Climate and fertility amid a public health crisis

One line of enquiry in demographic research assesses whether climate affects fertility. We extend this literature by examining the ramifications of climate conditions on fertility over a period of public health crisis in a highly unequal, urban middle-income country. We use monthly data for Brazil's 5,564 municipalities and apply spatial fixed-effects models to account for unobserved municipal heterogeneity and spatial dependence. Findings suggest that increases in temperature and precipitation are associated with declines in births. We also show that changes in response to climate conditions became greater during the Zika epidemic, particularly in urban areas. Combined, findings highlight the value of understanding the intersections between climate and fertility across geographic boundaries and during this public health crisis. Epidemics have become more important in people's lives with the recurring emergence of novel infectious disease threats, such as Zika and Covid-19.

Reduction in contraceptive use during the COVID-19 pandemic among women in an indigenous Mexican community: a retrospective crossover study

Background

Being indigenous, being a woman, and living in poverty are social determinants that contribute to reduced access to healthcare, including reproductive health services. The COVID-19 pandemic might have exacerbated this lag.

Objective

This study explored how the COVID-19 pandemic affected the contraceptive use of a group of indigenous Mexican women and adolescents in their community.

Methods

Between June and December of 2021, 158 indigenous Mexican women who had experienced recurrent pregnancies were interviewed at two health centers in San Cristóbal de las Casas, Chiapas. Participants were either pregnant when they completed the questionnaire or had been pregnant during the COVID-19 pandemic. Women were asked about their contraceptive practices before and during the pandemic. The change in contraceptive practice was estimated using a logistic model.

Results

The COVID-19 pandemic reduced contraceptive use by 50%. Among women who wanted contraception, 58% did not receive it. During the pandemic, 77% of previous contraceptive users reported difficulty obtaining contraception, and only 23% sought family planning assistance.

Conclusion

During the COVID-19 pandemic, indigenous women in the studied community used fewer contraceptive methods and did not use intrauterine devices. Additionally, there was a decline in the percentage of women using contraceptives. These results highlight the impact on indigenous populations and the difficulties they could face in accessing reproductive health services during health emergencies.

Women's Attitudes Towards Abortion in Response to the Zika and COVID-19 Outbreaks in Brazil

Introduction

Abortion attitudes are influenced by people's socioeconomic and demographic circumstances and can be volatile during times of crisis. Brazil is an interesting case for examining abortion attitudes because of its strict abortion policies, changing religious landscape, high income inequality, and extreme uncertainty generated by the back-to-back Zika and COVID-19 crises. This study seeks to assess Brazilian women's attitudes toward abortion and whether religion and income explain these attitudes in the context of novel infectious disease epidemics.

Methods

We used data from a population-based sample of 3996 women ages 18-34 in Pernambuco, Brazil, collected during the onset of the COVID-19 pandemic (May-September 2020). We conducted paired t-tests and multivariate-adjusted logistic regression models with adjusted Odds Ratios (aORs) and 95% CIs to assess differences in support for abortion in the case of fetal congenital Zika syndrome (CZS), maternal Zika infection during pregnancy, and maternal COVID-19 infection during pregnancy.

Results

Significantly more women support the right to abortion in the case of fetal CZS (50%) than in the case of maternal Zika infection (40%) and maternal COVID-19 infection (31%). Support for abortion varies by income and religion. Controlling for other demographic characteristics, high-income women have higher odds of supporting abortion in the case of fetal CZS (aOR = 1.92; 95% CI: 1.25-2.94) and maternal Zika infection (aOR = 2.07; 95% CI: 1.33-3.21) than low-income women. Evangelical women have lower odds of supporting abortion in the case of maternal Zika infection (aOR = 0.65; 95% CI: 0.45-0.93) and marginally lower odds of supporting the right to abortion in the case of maternal COVID-19 infection (aOR = 0.69; 95% CI: 0.47-1.00) than women of other religious affiliations.

Conclusions and Policy Implications

With increasingly conservative religious groups gaining size in Brazil, we expect to see increasing abortion restrictions. However, this research finds that a sizable portion of women across all incomes and religious affiliations support abortion, particularly in the case of fetal anomalies associated with Zika.

Unwanted sexual activity among United States women early in the COVID-19 pandemic

BACKGROUND

Female sexual activity and, accordingly, birth rates tend to decline in times of stress, such as a pandemic. In addition, when resources are scarce or exogenous conditions are threatening, some women may engage in sexual activity primarily to maintain socioeconomic security. Having unwanted sex may indicate sexual activity in exchange for economic security.

OBJECTIVE

This study aimed to describe patterns and correlates of unwanted sex, defined as having sex more frequently than desired, among US women early in the COVID-19 pandemic.

STUDY DESIGN

The National US Women's Health COVID-19 Study was conducted in April 2020, using a nested quota sample design to enroll 3200 English-speaking women (88% cooperation rate) aged 18 to 90 years recruited from a research panel. The quota strata ensured sufficient sample sizes in sociodemographic groups of interest, namely, racial and ethnic subgroups. Patterns of sexual activity, including unwanted sex early in the pandemic, were described. To further elucidate the experiences of women reporting unwanted sex, open-ended responses to an item querying "how the coronavirus pandemic is affecting your sex life" were assessed using conventional content analysis. Logistic regression analyses-adjusting for sociodemographic characteristics, self-reported health, and prepandemic health-related socioeconomic risk factors, including food insecurity, housing instability, utilities and transportation difficulties, and interpersonal violence-were used to model the odds of unwanted sex by a pandemic-related change in health-related socioeconomic risk factors.

RESULTS

The proportion of women who were sexually active early in the pandemic (51%) was about the same as in the 12 months before the pandemic (52%), although 7% of women became active, and 7% of women became inactive. Overall, 11% of sexually active women were having unwanted sex in the early pandemic. The rates of anxiety, depression, traumatic stress symptoms, and each of the 5 health-related socioeconomic risk factors assessed were about 2 times higher among women having unwanted sex than other women (P<.001). Women having unwanted sex were also 5 times more likely than other women to report an increased frequency of sex since the pandemic (65% vs 13%; P<.001) and 6 times more likely to be using emergency contraception (18% vs 3%; P<.001). Women reporting unwanted sex commonly described decreased libido or interest in sex related to mood changes since the pandemic, having "more sex," fear or worry about the transmission of the virus because of sex, and having sex to meet the partner's needs. Among sexually active women, the odds of unwanted sex (adjusting for demographic, reproductive, and health factors) were higher among women with 1 prepandemic health-related socioeconomic risk factor (adjusted odds ratio, 2.0; 95% confidence interval, 1.1-3.8) and 2 or more prepandemic health-related socioeconomic risk factors (adjusted odds ratio, 6.0; 95% confidence interval, 3.4-10.6). Among sexually active women with any prepandemic health-related socioeconomic risk factor, those with new or worsening transportation difficulties early in the pandemic were particularly vulnerable to unwanted sex (adjusted odds ratio, 2.7; 95% confidence interval, 1.7-4.3).

CONCLUSION

More than 1 in 10 sexually active US women was having unwanted sex early in the COVID-19 pandemic. Socioeconomically vulnerable women, especially those with new or worsening transportation problems because of the pandemic, were more likely than others to engage in unwanted sex. Pandemic response and recovery efforts should seek to mitigate unwanted sexual activity and related health and social risks among women.

The Zika virus: an opportunity to revisit reproductive health needs and disparities

First isolated in 1947, the Zika virus was initially connected only to limited or sporadic human infections. In late 2015, the temporal clustering of a Zika outbreak and microcephaly in newborn babies from northeastern Brazil, and the identification of a causal link between the two, led to the characterization of the congenital Zika syndrome. In the wake of the epidemic, several countries from Latin America advised women to postpone pregnancies for periods ranging from six months to two years. These recommendations initiated critical conversations about the challenges of implementing them in societies with limited access to contraception, widespread socioeconomic inequalities, and high rates of unplanned and adolescent pregnancies. The messaging targeted exclusively women, despite a high prevalence of imbalances in the relationship power, and addressed all women as a group, failing to recognize that the decision to postpone pregnancies will impact different women in different ways, depending on their age at the time. Finally, in several countries affected by the Zika epidemic, due to restrictive reproductive policies, legally terminating a pregnancy is no longer an option even at the earliest time when brain malformations as part of the congenital Zika syndrome can be detected by ultrasonography. The virus continued to circulate after 2016 in several countries. Climate change models predict an expansion of the geographical area where local Zika transmission may occur, indicating that the interface between the virus, teratogenesis, and reproductive rights is a topic of considerable interest for medicine, social sciences, and public health for years to come.

Experiences of women raising children with congenital Zika syndrome along a trajectory of prevention, care and support in Brazil

Social science research investigating the social dynamics of Zika and congenital Zika syndrome (CZS) is essential to inform future services related to Zika and other infectious diseases. We sought to understand lived experiences with Zika during pregnancy, birth, and post-partum by conducting in-depth interviews with a sample of 31 women infected with Zika during the 2015-16 outbreak who had a child with CZS in Pernambuco, Brazil. Transcripts were coded using thematic content analysis. Many women experienced shock when their children were born with CZS given the lack of information they were provided during the antenatal period. Stigma from loved ones and community members was a salient theme as were financial difficulties arising from women having to stop working to care for their child. While women experienced significant challenges caring for a child with CZS, they also exhibited resiliency in their ability to move from shock and sorrow to focusing on the needs of their child. While support services were generally available, they were often located at a significant distance. Results underscore the need for interventions to improve patient-provider communication, address socio-structural stressors, and support individual and collective resilience in women and families affected by Zika in lower resource settings.

"It changed the atmosphere surrounding the baby I did have": Making sense of reproduction during the COVID-19 pandemic

OBJECTIVE

This study examines the schemas that women employed during the COVID-19 pandemic to make sense of their reproductive desires.

BACKGROUND

Existing research on reproduction during epidemics suggests that there are variable population responses to periods of long-term social uncertainty. However, less is known about how individuals make sense of maintaining or adapting their reproductive desires during periods of social upheaval.

METHOD

Twenty-nine women aged 25-35 from a mid-sized Midwestern county in the United States were recruited and interviewed about their experiences during the first 8 months of the COVID-19 pandemic. They were asked about their daily lived experiences and their reproductive desires during in-depth interviews. These interviews were transcribed and analyzed using thematic coding.

RESULTS

Participants used three normative schemas to describe their reproductive desires during the COVID-19 pandemic. Heteronormative schemas were used by many participants to articulate their commitment to a heteronormative aged-staged timeline of life events. Schemas of social support around being pregnant and giving birth were used by participants, primarily those who were currently or recently pregnant, to express grief and loss over the relational experience of having a new baby. Medicalized schemas were expressed by most participants to describe feelings of fear and risk at real or imagined encounters with medical institutions.

CONCLUSION

The schemas that participants used to make sense of their reproductive desires demonstrate how sense-making during a profound event that affects everyday realities allows participants to (re)articulate commitments to existing narratives that reinforce heterosexual, social, and medicalized hierarchies in reproduction.

The illusion of stable fertility preferences

Fertility preferences have long played a key role in models of fertility differentials and change. We examine the stability of preferences over time using rich panel data on Kenyan women's fertility desires, expectations, actual fertility, and recall of desires in three waves over a nine-year period, when respondents were in their 20s. We find that although desired fertility is quite unstable, most women perceive their desires to be stable. Under hypothetical future scenarios, few expect their desired fertility to increase over time but, in fact, such increases in fertility desires are common. Moreover, when asked to recall past desires, most respondents report previously wanting exactly as many children as they desire today. These patterns of bias are consistent with the emerging view that fertility desires are contextual, emotionally laden, and structured by identity.

Congenital Zika syndrome and living conditions in the largest city of northeastern Brazil

Background

The Zika virus (ZIKV) epidemic hit Brazil in 2015 and resulted in a generation of children at risk of congenital Zika syndrome (CZS). The social vulnerability of certain segments of the population contributed to the disproportional occurrence of CZS in the Brazilian Northeast, the poorest region in the country. Living conditions are essential factors in understanding the social determination of CZS, which is embedded in a complex interaction between biological, environmental, and social factors. Salvador, the biggest city in the region, played a central role in the context of the epidemic and was a pioneer in reporting the ZIKV infection and registering a high number of cases of CZS. The aim of the study was identifying the incidence and spatial distribution pattern of children with CZS in the municipality of Salvador, according to living conditions.

Methods

This is an ecological study that uses the reported cases of ZIKV and CZS registered in the epidemiological surveillance database of the Municipal Secretariat of Health of the city of Salvador between August of 2015 and July of 2016. The neighborhoods formed the analysis units and the thematic maps were built based on the reported cases. Associations between CZS and living conditions were assessed using the Kernel ratio and a spatial autoregressive linear regression model.

Results

Seven hundred twenty-six live births were reported, of which 236 (32.5%) were confirmed for CZS. Despite the reports of ZIKV infection being widely distributed, the cases of CZS were concentrated in poor areas of the city. A positive spatial association was observed between living in places with poorer living conditions and births of children with CZS.

Conclusions

This study shows the role of living conditions in the occurrence of births of children with CZS and indicates the need for approaches that recognize the part played by social inequalities in determining CZS and in caring for the children affected.

Fertility decision-making during the Zika virus epidemic in Brazil: Where is the decision?

BACKGROUND

In 2016, a Public Health Emergency of International Concern (PHEIC) was declared in response to the rise of microcephaly cases among newborns in Northeastern Brazil. A common reactionary measure by public health authorities was to recommend women postpone pregnancy to avoid the possible perinatal transmission of Zika virus (ZIKV).

METHODS

The purpose of this study was to assess how women in Fortaleza, Brazil conceptualize pregnancy; experience facilitators and barriers to pregnancy avoidance; perceive the authorities' recommendation to postpone pregnancy due to the ZIKV outbreak; and recall their experiences during the ZIKV epidemic. Qualitative methods, specifically a Rapid Anthropological Assessment (RAA), were utilized in this study. Data collection included semi-structured interviews, triangulated with observations and informal interviews with community members.

RESULTS

The sample included 35 women (18-39 years old) who exclusively utilized the national public health care system. Findings indicated that all participants perceived the ZIKV pregnancy-postponement recommendation to be counter-cultural to Brazilian social norms. Overall women's self-perceived agency to prevent pregnancy was low due to social expectations and lack of trust for contraceptives. ZIKV prevention was not seen as a reason to utilize contraceptives. Interestingly, only women who self-perceived as more affluent were willing to attempt pregnancy prevention for educational, occupational, or financial opportunity.

CONCLUSION

Pregnancy postponement as a response to a ZIKV epidemic ignores gaps in reproductive agency and defies social norms, making it unrealistic and counter-cultural. Future ZIKV health recommendations must be culturally aligned with the population, and address barriers and motivators for family planning.

Stability and change in fertility intentions in response to the COVID-19 pandemic in Kenya

Fertility intentions are expected to decline due to the COVID-19 pandemic but limited empirical research on this topic has been conducted in sub-Saharan Africa. Longitudinal data from Kenya, with baseline (November 2019) and follow-up (June 2020) data, were used to 1) assess the extent to which individual-level fertility intentions changed, and 2) examine how security, specifically economic and health security, affected fertility intentions. The final sample included 3,095 women. The primary outcomes were change in quantum and timing. Exploratory analyses described overall changes within the sample and logistic regression models assessed sociodemographic and COVID-19 related correlates of change, specifically income loss at the household level, food insecurity, and ability to socially distance. Approximately 85% of women reported consistent fertility intentions related to both the number and timing of childbearing. No COVID-19-related factors were related to changing quantum intentions. Women who reported chronic food insecurity had 4.78 times the odds of accelerating their desired timing to next birth compared to those who reported no food insecurity (95% CI: 1.53-14.93), with a significant interaction by wealth. The COVID-19 pandemic did not lead to widespread changes in fertility intentions in Kenya, though the most vulnerable women may have accelerated their childbearing intentions.

Abortion in the times of Zika: the perspective of women in two Brazilian municipalities

In Brazil, abortion is considered a crime under the Criminal Code since 1940. After the Zika virus epidemic (2015-2017) and the consequent appearance of microcephaly in newborns struck South America, the debate on the decriminalization of abortion in the Brazilian society was reignited. Using data obtained from focus groups comprising women of reproductive age across different socioeconomic strata and two Brazilian cities, we investigated the perceptions of the participants on abortion, especially its use during the Zika epidemic. Although legally criminalized, abortion is prevalent among women, as a way to fulfill their reproductive desire. Criminalization puts the health and lives of women at risk, particularly those with less economic and cultural capital. We also discover the role of friends in women's decision to utilize the procedure. The strong asymmetry of power between men and women contributes to the greater vulnerability of women. The results suggest an urgent need to review the legislation on abortion concerning its criminalization and the option of safer abortion within the scope of the public health service.

Maternal Pregnancy Intention and Developmental Outcomes in Brazilian Preschool-Aged Children

OBJECTIVE

This study aims to characterize the association between maternal pregnancy intention and socioemotional developmental outcomes in a Brazilian sample of preschool-aged children.

METHODS

Data from children aged 4 to 5 years and their primary caregivers in Embu das Artes, a Brazilian municipality in the state of São Paulo, were collected in 2016. Maternal pregnancy intention was defined as intended or unintended, which was then further stratified as mistimed or unwanted. Outcomes included socioemotional developmental delay, internalizing and externalizing behaviors, and school readiness. We estimated risk ratios (RRs) for unadjusted and inverse-probability-weighted regression adjustment (IPWRA) analyses using 2-level (intended vs unintended) and 3-level (intended vs mistimed vs unwanted) exposure definitions.

RESULTS

Of 1,034 total mothers, 40.7% reported their pregnancy as intended, 46.0% as mistimed, and 13.4% as unwanted. In both unadjusted and IPWRA analyses comparing intended and unintended pregnancies, all associations failed to reach statistical significance. In the IPWRA analysis using the 3-level exposure definition, unwanted pregnancies were associated with higher risk of socioemotional developmental delay (RR = 1.14; 95% confidence interval [CI], 1.01-1.28) and co-occurring internalizing and externalizing behaviors (RR = 1.11, 95% CI, 1.00-1.22), compared with intended pregnancies.

CONCLUSION

There was higher risk of poor child outcomes among unwanted compared with intended pregnancies, whereas mistimed pregnancies were not associated with poor outcomes. Further research using standardized definitions of pregnancy intention along with targeted interventions that increase access to family planning services and counseling for parents of children born after unintended pregnancies is needed.

Contraceptive dynamics during COVID-19 in sub-Saharan Africa: longitudinal evidence from Burkina Faso and Kenya

INTRODUCTION

Evidence from health emergencies suggests COVID-19 will disrupt women's sexual and reproductive health (SRH). In sub-Saharan Africa, which experiences the highest rates of unintended pregnancy and unsafe abortion globally, COVID-19 is projected to slow recent progress toward universal access to contraceptive services.

METHODS

We used longitudinal data collected from women at risk of unintended pregnancy in Burkina Faso (n=1186) and Kenya (n=2784) before (November 2019-February 2020) and during (May-July 2020) COVID-19 to quantify contraceptive dynamics during COVID-19; examine sociodemographic factors and COVID-19 experiences related to contraceptive dynamics; and assess COVID-19-related reasons for contraceptive non-use. Bivariate and multivariate logistic regressions were used to examine correlates of contraceptive dynamics amid COVID-19.

RESULTS

Most women did not change their contraceptive status during COVID-19 (68.6% in Burkina Faso and 81.6% in Kenya) and those who did were more likely to adopt a method (25.4% and 13.1%, respectively) than to discontinue (6.0% and 5.3%, respectively). Most women who switched contraceptives were using methods as or more effective than their pre-pandemic contraception. Economic instability related to COVID-19 was associated with increased contraceptive protection in Burkina Faso but not in Kenya. Altogether, 14.4% of non-contraceptive users in Kenya and 3.8% in Burkina Faso identified COVID-19-related reasons for non-use.

CONCLUSIONS

The vast majority of women at risk of unintended pregnancy did not change their contraceptive status during COVID-19, and more women adopted than discontinued methods. A minority of women reported COVID-19-related reasons for non-use, underscoring the importance of expanding safe modes of service delivery during health crises.

Scoping Review on the Impact of Outbreaks on Sexual and Reproductive Health Services: Proposed Frameworks for Pre-, Intra-, and Postoutbreak Situations

Introduction

Recent experiences from global outbreaks have highlighted the severe disruptions in sexual and reproductive health services that expose women and girls to preventable health risks. Yet, to date, there is no review studying the possible impact of outbreaks on sexual and reproductive health (SRH). Methodology. Studies reporting outbreaks impacting sexual and reproductive health and pregnancy outcomes were identified using MEDLINE, Embase, and ISI-WoS. Reported impacts were reviewed at systems, community, and legislative levels.

Results

The initial run listed 4423 studies; the 37 studies that met all inclusion criteria were mainly from Latin America and Africa. Studies on outbreaks of diseases like Zika and Ebola have documented declines in facility-based deliveries, contraceptive use, and antenatal and institutional care due to burdened healthcare system. Service usage was also impacted by a lack of trust in the healthcare system and system shocks, including workforce capacity and availability. At the community level, poverty and lack of awareness were critical contributors to poor access to SRH services. Assessing the target population's knowledge, attitude, beliefs, and behavior and using health literacy principles for communication were fundamental for designing service delivery. Online resources for SRH services were an acceptable medium of information among young adults. In outbreak situations, SRH and pregnancy outcomes were improved by implementing laboratory surveillance, free-of-cost contraceptive services, improved screening through professional training, and quality of care. In addition, mobile health clinics were reported to be effective in remote areas. Knowledge Contribution. In outbreaks, the interventions are categorized into preoutbreak, during, and postoutbreak periods. The proposed steps can help to improve and do course correction in emergencies. Though conducted before the COVID-19 crisis, the authors believe that lessons can be drawn from the paper to understand and mitigate the impact of the pandemic on sexual and reproductive health services.

Public health messages on arboviruses transmitted by Aedes aegypti in Brazil

BACKGROUND

The outbreak of Zika virus in Brazil in 2015 followed the arrival of chikungunya in 2014 and a long history of dengue circulation. Vital to the response to these outbreaks of mosquito-borne pathogens has been the dissemination of public health messages, including those promoted through risk communication posters. This study explores the content of a sample of posters circulated in Brazil towards the end of the Zika epidemic in 2017 and analyses their potential effectiveness in inducing behaviour change.

METHODS

A content analysis was performed on 37 posters produced in Brazil to address outbreaks of mosquito-borne pathogens. The six variables of the Health Belief Model were used to assess the potential effectiveness of the posters to induce behaviour change.

RESULTS

Three overarching key messages emerged from the posters. These included (i) the arboviruses and their outcomes, (ii) a battle against the mosquito, and (iii) a responsibility to protect and prevent. Among the six variables utilised through the Health Belief Model, cues to action were most commonly featured, whilst the perceived benefits of engaging in behaviours to prevent arbovirus transmission were the least commonly featured.

CONCLUSIONS

The posters largely focused on mosquito-borne transmission and the need to eliminate breeding sites, and neglected the risk of the sexual and congenital transmission of Zika and the importance of alternative preventive actions. This, we argue, may have limited the potential effectiveness of these posters to induce behaviour change.

How Nearby Homicides Affect Young Women's Pregnancy Desires: Evidence From a Quasi-Experiment

Leveraging spatiotemporal variation in homicides that occurred during a 2.5-year weekly panel survey of 387 women ages 18-22 in Flint, Michigan, we investigate how young women's desires to become pregnant and to avoid pregnancy evolve in response to local homicides during the transition to adulthood. To address the endogeneity of exposure, we explore how the same woman's pregnancy desires (1) differed, on average, across weeks before and after the first homicide occurred within a quarter mile of her home; (2) evolved in the aftermath of this initial homicide exposure; and (3) changed in response to additional nearby homicides. One-fifth (22%) of women were exposed to a nearby homicide at least once during the study, and one-third of these women were exposed multiple times. Overall, the effects of nearby homicides were gradual: although average desires to become pregnant and to avoid pregnancy differed after initial exposure, these differences emerged approximately three to five months post-exposure. Repeated exposure to nearby homicides had nonlinear effects on how much women wanted to become pregnant and how much they wanted to avoid pregnancy. Together, our analyses provide a new explanation for why some young women-especially those who are socially disadvantaged-desire pregnancy at an early age.

The influence of vector-borne disease on human history: socio-ecological mechanisms

Vector-borne diseases (VBDs) are embedded within complex socio-ecological systems. While research has traditionally focused on the direct effects of VBDs on human morbidity and mortality, it is increasingly clear that their impacts are much more pervasive. VBDs are dynamically linked to feedbacks between environmental conditions, vector ecology, disease burden, and societal responses that drive transmission. As a result, VBDs have had profound influence on human history. Mechanisms include: (1) killing or debilitating large numbers of people, with demographic and population-level impacts; (2) differentially affecting populations based on prior history of disease exposure, immunity, and resistance; (3) being weaponised to promote or justify hierarchies of power, colonialism, racism, classism and sexism; (4) catalysing changes in ideas, institutions, infrastructure, technologies and social practices in efforts to control disease outbreaks; and (5) changing human relationships with the land and environment. We use historical and archaeological evidence interpreted through an ecological lens to illustrate how VBDs have shaped society and culture, focusing on case studies from four pertinent VBDs: plague, malaria, yellow fever and trypanosomiasis. By comparing across diseases, time periods and geographies, we highlight the enormous scope and variety of mechanisms by which VBDs have influenced human history.

[Meanings, risk perceptions, and prevention strategies for pregnant women since the emergence of the Zika virus in Brazil]

This study aimed to understand the meanings, risk perceptions, and strategies to prevent infection with the Zika virus developed by pregnant women with different socioeconomic conditions seen at public and private health services in the city of Salvador, Bahia State, Brazil, as well the contribution by their male partners in dealing with the risk of infection since the emergence of this virus in Brazil. A qualitative study was performed with 18 semi-structured interviews, nine each with pregnant women seen in the public and private health systems, respectively. The resulting data revealed insufficient knowledge in pregnant women concerning important aspects of Zika virus infection. The pregnant women's socioenvironmental situation was an important factor for risk perception and preventive strategies. Women interviewed in the public health system felt more vulnerable to the risk of infection than women interviewed in the private health system, with a major impact on their psychosocial well-being. According to the women, their partners placed huge demands on them to adopt preventive measures, but the male partners themselves failed to take the same precautions, e.g., ignoring the risk of sexual transmission of the Zika virus. In conclusion, three years since the outbreak reached Brazil, the Zika virus still has a major impact on the lives of pregnant women. It is crucial to strengthen health communications activities to guarantee the availability of information on the disease that responds adequately to the population's needs.

Zika virus public health crisis and the perpetuation of gender inequality in Brazil

BACKGROUND

In 2015-2017, the Americas experienced a highly consequential epidemics for pregnancy and childbearing. Mainly transmitted by the mosquito Aedes aegypti, but also through sexual intercourse, the Zika virus poses the risk of congenital Zika syndrome to fetus, which includes microcephaly and other child development complications. When a public health crisis taps directly into reproductive health, typically a feminine realm, responses to the emergency may exacerbate deeply-rooted gender norms. This paper investigates the role of gender in two relational contexts: (a) the government-led response to the pandemic in terms of communication campaigns aimed at preventing Zika infections; and (b) an individual level of response to the emergency, concerning women's negotiation with their sexual partners with regard to the prevention of Zika as well as pregnancies.

METHODS

We conducted content analysis of 94 unique pieces from public health communication campaigns produced by governmental agencies with the goal of promoting Zika awareness. Print and online materials were collected from May 2016 to August 2017, and included TV ads, Internet Pop-ups, and pamphlets. We also analyzed transcripts from 16 focus groups conducted with reproductive-aged women (18-40) in Belo Horizonte and Recife, two large cities differently affected by the Zika outbreak. Women answered open-ended questions connected to the epidemic, in areas such as personal knowledge and experiences with the Zika virus, experiences of their friends and acquaintances, their primary information sources, their perceptions of public health efforts toward containing the outbreak, as well as women's contraceptive use.

RESULTS

Campaign pieces handling pregnancy and microcephaly were largely gendered. Pieces targeted women, placing on their shoulders the responsibility for protecting a potential fetus from the disease. Importantly, campaigns neglected addressing male's participation on Zika prevention and contraceptive management, while failing to take into account Brazil's large proportion of unplanned pregnancies. Women were placed in a double bind by being expected to prevent both pregnancy and Zika, in a context where gendered power imbalances often translate in women having little power/means for condom negotiation/avoiding unprotected sexual intercourse.

CONCLUSION

Government and individual responses to the epidemics reinforced gender roles, situating pregnant women as responsible for averting mosquito bites and microcephaly. Further, prevention campaigns largely excluded men. Since low-socioeconomic status women possessed fewer resources to preclude infection, we also found that beyond the gender divide, this subgroup faced more pronounced Zika prevention challenges as they found it harder to negotiate condom use with their sexual partners and often could not access other types of contraceptives resulting in unplanned pregnancies.

Analysing the intersection between health emergencies and abortion during Zika in Brazil, El Salvador and Colombia

The Zika outbreak of 2015-7 is a lens to analyse the positioning of abortion within in global health security. The sequelae of the virus almost exclusively affected newborn children, manifested through Congenital Zika Syndrome (CZS), and a focus on women at risk of, planning or being pregnant. At the global level, debate considered whether Zika would provide impetus for regulatory change for reproductive rights in Latin America, a region with some of the most restrictive abortion regulation in the world. However, regulatory change for abortion did not occur. We analyse why the Zika health emergency did not lead to any changes in abortion regulation through multi-method analysis of the intersection between Zika, health emergencies and abortion in Brazil, Colombia and El Salvador. These case study countries were purposefully selected; each had Zika infected women (albeit with differing incidence) yet represent diverse regulatory environments for abortion. Our comparative research is multi-method: framework analysis of key informant interviews (n = 49); content analysis of women's enquiries to a medical abortion telemedicine provider; and, policy analysis of (inter)national-level Zika response and abortion policies. We consider this within literature on global health security, and the prioritisation of a particular approach to epidemic control. Within this securitized landscape, despite increased public debate about abortion regulatory change, no meaningful change occurred, due to a dominant epidemiological approach to the Zika health emergency in all three countries and prominent conservative forces in government and within anti-abortion rights movements. Simultaneously, we demonstrate that regulation did not deter all women from seeking such service clandestinely.

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Zika affected reproductive decision making, but did not impact abortion regulation.

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Epidemiological framing ignored reproductive dimensions of emergency responses.

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Conservative forces instrumentalized disability concerns to oppose abortion rights.

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Women sought abortions clandestinely, citing Zika as a justification.

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Abortion provision must form part of health emergency planning and response.

Discussões sobre os direitos sexuais e reprodutivos das mulheres após o surgimento do zika vírus no Brasil

Resumo Este estudo buscou compreender como a epidemia do zika vírus e suas consequências sobre o desenvolvimento fetal influenciaram a percepção de gestantes de diferentes situações socioeconômicas sobre os direitos sexuais e reprodutivos em uma capital da região nordeste do Brasil. Trata-se de uma pesquisa qualitativa, desenvolvida a partir de dezoito entrevistas semiestruturadas, sendo nove com gestantes do setor público de saúde e nove com gestantes do setor privado de saúde. Os resultados demonstraram que entre gestantes atendidas pelo setor público de saúde há uma alta ocorrência de gestações não intencionais, relacionadas principalmente a dificuldades no acesso aos serviços de saúde e informação. As gestantes de uma maneira geral passaram a desenvolver cuidados a fim de reduzir o risco de infecção pelo zika vírus, comportamento não compartilhado por seus parceiros, apesar da possibilidade de transmissão sexual do vírus. Por fim, a ampliação da discussão sobre os direitos reprodutivos, proposta pela Ação Direta de Inconstitucionalidade 5581, ainda divide opiniões entre as mulheres quanto a possibilidade de interrupção da gestação em casos de infecção pelo zika vírus, sendo que as argumentações favoráveis denunciam as injustiças sociais, enquanto as contrárias mobilizam questões de cunho moral e religioso.

Brazil's Missing Infants: Zika Risk Changes Reproductive Behavior

Zika virus epidemics have potential large-scale population effects. Controlled studies of mice and nonhuman primates indicate that Zika affects fecundity, raising concerns about miscarriage in human populations. In regions of Brazil, Zika risk peaked months before residents learned about the epidemic and its relation to congenital anomalies. This spatiotemporal variation supports analysis of both biological effects of Zika infection on fertility and the effects of learning about Zika risk on reproductive behavior. Causal inference techniques used with vital statistics indicate that the epidemic caused reductions in birth cohort size of approximately one-quarter 18 months after Zika infection risk peaked but 10 months after public health messages advocated childbearing delay. The evidence is consistent with small but not statistically detectable biological reductions in fecundity, as well as large strategic changes in reproductive behavior to temporally align childbearing with reduced risk to infant health. The behavioral effects are larger for more-educated and older women, which may reflect facilitated access to information and to family planning services within high-risk, mosquito-infested urban locations as well as perceptions about the opportunity costs of risks to pregnancy and infant survival.

Requests for medication abortion support in Brazil during and after the Zika epidemic

Brazil declared a public health emergency during the Zika virus epidemic, recommending avoiding pregnancy. This study analyses requests received by Women Help Women for information about and support for self-managed medication abortion (MA) in Brazil during and after the Zika epidemic to understand how Zika may have impacted requests to the service. This analysis considered 20,609 requests for MA support received between January 2016 and June 2017. Reasons for seeking an abortion were analysed alongside geographic trends in the percent and rate of requests citing Zika as a reason for seeking abortion. The average number of daily requests for MA support increased from 31 in January 2016 to 48 in June 2017. The average percent of daily requests citing Zika as a reason for seeking an abortion decreased from 15% in March 2016 to 1.5% by June 2017. The most common reason for abortion seeking during and after the Zika epidemic was not being prepared for a child or not wanting any or additional children (between 52%-59% of requests). As the Zika epidemic slowed, MA requests citing Zika as a reason decreased, while requests increased overall. Few people cited Zika alone as a reason for abortion seeking, necessitating a broad contextualisation of abortion access in people's daily lived experiences and realities.

"Too Much to Ask, Too Much to Handle": Women's Coping in Times of Zika

Zika virus infection during pregnancy is a cause of congenital brain abnormalities. Its consequences for pregnancies have made governments and both national and international agencies issue advice and recommendations to women. This study was designed to understand the impacts of Zika on women who were less directly affected and less vulnerable to Zika. Women were recruited from various locations in Brazil, Puerto Rico, and the United States. Data were collected through semi-structured interviews and analyzed using thematic analysis. Women perceived that public health systems placed an unfair responsibility for preventing health complications from Zika onto women who had limited ability to do so. They also stated that the measures recommended to them were invasive, while creating the perception that women were the sole determinant of whether they contracted Zika. The results indicate that women with higher levels of education understood the limitations of the information, government actions, and medical care they received, which ended up producing higher levels of anguish and worry. Gender inequality and discrimination must be recognized and rendered visible in the public health emergency response. The social effects of the epidemic affected women more than had been thought before and at deeper emotional levels.

Live Births and Fertility Amid the Zika Epidemic in Brazil

In late 2015, the Brazilian Ministry of Health and the Pan American Health Organization classified the increase in congenital malformations associated with the Zika virus (ZIKV) as a public health emergency. The risk of ZIKV-related congenital syndrome poses a threat to reproductive outcomes that could result in declining numbers of live births and potentially fertility. Using monthly microdata on live births from the Brazilian Information System on Live Births (SINASC), this study examines live births and fertility trends amid the ZIKV epidemic in Brazil. Findings suggest a decline in live births that is stratified across educational and geographic lines, beginning approximately nine months after the link between ZIKV and microcephaly was publicly announced. Although declines in total fertility rates were small, fertility trends estimated by age and maternal education suggest important differences in how Zika might have impacted Brazil's fertility structure. Further findings confirm the significant declines in live births in mid-2016 even when characteristics of the municipality are controlled for; these results highlight important nuances in the timing and magnitude of the decline. Combined, our findings illustrate the value of understanding how the risk of a health threat directed at fetuses has led to declines in live births and fertility.

Understanding sexual and reproductive health needs of young women living in Zika affected regions: a qualitative study in northeastern Brazil

Background

In 2016, the World Health Organization declared a Public Health Emergency of International Concern due to Zika’s association with microcephaly and other neurological disorders. Brazil was the epicenter of this epidemic and the most affected region has the lowest Human Development Index and the highest rates of adolescent pregnancy. Despite the end of the epidemic, Brazil continues to be the epicenter of Zika illness. This study examined the barriers faced by young women who seek sexual and reproductive health (SRH) care services living in affected areas and their attitudes towards SRH needs and the available services.

Methods

Individual semi-structured interviews were conducted with 22 young women, aged 14–24 years in three Zika affected municipalities in the Brazilian Northeast. This qualitative research used thematic analysis for data analysis.

Results

Almost half (n = 10) of the participants had their first pregnancy during adolescence (from 12 to 19), all of which were unintended. Lack of information and barriers to access family planning were found to contribute to the unmet need for contraception. Participants reported knowledge gaps about contraception. Zika was not considered a health concern and participants were unaware of the possibility of Zika’s sexual transmission.

Conclusions

The young women’s knowledge and attitudes towards their SRH needs highlight the barriers to access care. It also implies that comprehensive, biopsychosocial and political, understanding is necessary in order to adequately provide SRH to this population and meet their needs. The government should place women at the center of any public health response to an emergency affecting women of reproductive age and focus on improving access to information and family planning services in a culturally and age appropriate manner.

Evidence-Based Process for Prioritizing Positive Behaviors for Promotion: Zika Prevention in Latin America and the Caribbean and Applicability to Future Health Emergency Responses

To maximize the impact of Zika prevention programming efforts, a prioritization process for social and behavior change programming was developed based on a combination of research evidence and programmatic experience. Prioritized behaviors were: application of mosquito repellent, use of condoms, removing unintentional standing water, covering and scrubbing walls of water storage containers, seeking prenatal care, and seeking counseling on family planning if not planning to get pregnant.

Since the 2015 Zika outbreak in Latin America and the Caribbean, a plethora of behavior change messages have been promoted to reduce Zika transmission. One year after the United States Agency for International Development (USAID) initiated its Zika response, more than 30 variants of preventive behaviors were being promoted. This situation challenged social and behavior change (SBC) programming efforts that require a coordinated response and agreed upon set of focus behaviors to be effective. To support USAID implementing partners in harmonizing prevention efforts to reduce Zika infection, we developed an evidence-based process to identify behaviors with the highest potential to reduce Zika infection and transmission. We compiled a full list of behaviors and selected the most promising for a full evidence review. The review included systematic keyword searches on Google Scholar, extraction of all relevant published articles on Aedes-borne diseases between 2012 and 2018, review of seminal papers, and review of gray literature. We examined articles to determine each behavior's potential effectiveness in preventing Zika transmission or reducing the Aedes aegypti population. We also developed assessment criteria to delineate the ease with which the target population could adopt each behavior, including: (1) required frequency; (2) feasibility of the behavior; and (3) accessibility and cost of the necessary materials in the setting. These behaviors were refined through a consensus-building process with USAID's Zika implementing partners, considering contextual factors. The resulting 7 evidence-based preventive behaviors have high potential to strengthen SBC programming's impact in USAID's Zika response: (1) apply mosquito repellent, (2) use condoms during pregnancy, (3) remove standing water, (4) cover water storage containers, (5) clean/remove mosquito eggs from water containers, (6) seek antenatal care, and (7) seek family planning counseling. This case study documents a flexible process that can be adapted to inform the prioritization of behaviors when there is limited evidence available, as during many emergency responses.

Zika, abortion and health emergencies: a review of contemporary debates

BACKGROUND

The Zika outbreak provides pertinent case study for considering the impact of health emergencies on abortion decision-making and/or for positioning abortion in global health security debates.

MAIN BODY

This paper provides a baseline of contemporary debates taking place in the intersection of two key health policy areas, and seeks to understand how health emergency preparedness frameworks and the broader global health security infrastructure is prepared to respond to future crises which implicate sexual and reproductive rights. Our paper suggests there are three key themes that emerge from the literature; 1) the lack of consideration of sexual and reproductive health (SRH) services in outbreak response 2) structural inequalities permeate the landscape of health emergencies, epitomised by Zika, and 3) the need for rights based approaches to health.

CONCLUSION

Global health security planning and response should specifically include programmatic activity for SRH provision during health emergencies.

Of mosquitoes and men: mitigating Zika risk via Men's family planning and male contraception

BACKGROUND

Outbreaks of mosquito-borne viral illnesses commonly occur after storms. As storms are predicted to worsen in intensity and frequency, mosquito-borne viruses, including the Zika virus are expected to spread, and with devastating consequences. While the disease is self-limited, pregnant women who contract Zika can transmit the virus to their fetuses, causing neurodevelopmental abnormalities, including microcephaly. An overlooked vector of the Zika virus, however, is men whose semen can transmit the virus at the time of sexual intercourse. Current recommendations for preventing the sexual transmission of Zika are inadequate and need to emphasize male reproductive responsibility, via expanding services for men's family planning and developing novel male contraceptives.

MAIN BODY

To prevent the sexual transmission of Zika, the World Health Organization recommends that couples use condoms or abstain from sexual activity for at least 6 months when traveling in Zika-infected areas. Strict adherence to these recommendations is neither practical nor adequate to address Zika's sexual transmission. As up to 13% of couples who use condoms experience unintended pregnancy, semen and consequent viral exposure is imminent. The use of contraception beyond just barrier methods is essential. However, the burden of contraception largely falls upon women and efforts to prevent vertical transmission are often aimed at educating women, when the outcome is equally undesirable among their male partners. These short-comings highlight the lack of attention to men's options for family planning. Educating men about the full range of contraceptive options, correcting misconceptions about the efficacy of withdrawal and barrier contraceptive methods, increasing access to vasectomy, and developing novel male contraceptive options would allow shared responsibility for the prevention of unintended pregnancy and Zika-related morbidity.

CONCLUSION

Gaps in recommendations to prevent the sexual transmission of Zika provide an opportunity to develop men's family planning initiatives and the range of accessible contraceptives to men.

The Zika Virus Epidemic in Brazil: From Discovery to Future Implications

The first confirmed case of Zika virus infection in the Americas was reported in Northeast Brazil in May 2015, although phylogenetic studies indicate virus introduction as early as 2013. Zika rapidly spread across Brazil and to more than 50 other countries and territories on the American continent. The Aedesaegypti mosquito is thought to be the principal vector responsible for the widespread transmission of the virus. However, sexual transmission has also been reported. The explosively emerging epidemic has had diverse impacts on population health, coinciding with cases of Guillain-Barré Syndrome and an unexpected epidemic of newborns with microcephaly and other neurological impairments. This led to Brazil declaring a national public health emergency in November 2015, followed by a similar decision by the World Health Organization three months later. While dengue virus serotypes took several decades to spread across Brazil, the Zika virus epidemic diffused within months, extending beyond the area of permanent dengue transmission, which is bound by a climatic barrier in the south and low population density areas in the north. This rapid spread was probably due to a combination of factors, including a massive susceptible population, climatic conditions conducive for the mosquito vector, alternative non-vector transmission, and a highly mobile population. The epidemic has since subsided, but many unanswered questions remain. In this article, we provide an overview of the discovery of Zika virus in Brazil, including its emergence and spread, epidemiological surveillance, vector and non-vector transmission routes, clinical complications, and socio-economic impacts. We discuss gaps in the knowledge and the challenges ahead to anticipate, prevent, and control emerging and re-emerging epidemics of arboviruses in Brazil and worldwide.