Unintended Pregnancies in Brazil - A Challenge for the Recommendation to Delay Pregnancy Due to Zika

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.

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.

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.

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.

Contraception and post abortion services: qualitative analysis of users' perspectives and experiences following Zika epidemic in Honduras

BACKGROUND

Zika virus (ZIKV) infection during pregnancy has severe consequences on the new-born. The World Health Organization declared the Zika outbreak to be a Public Health Emergency of International Concern (PHEIC) in 2016. Health facilities in the regions most affected by Zika lacked the capacity to respond to the increased demand for contraception. The objectives were to explore healthcare users' perceptions regarding contraception, Zika prevention during pregnancy and post-abortion care (PAC) services in the context of a Zika outbreak in Tegucigalpa, Honduras, and to follow these services over time.

METHODS

This study was part of a broader implementation research study. We used qualitative research consistent with grounded theory approach. Semi-structured interviews and focus groups were performed with women and their partners who used contraceptive services or received PAC services. Data were collected in two stages from December 2017 to July 2018. Themes explored included contraception, Zika and PAC services.

RESULTS

Participants had positive attitude towards the use of contraceptive methods and demanded more information on safety, efficacy and on side effects. Health care services were inconsistent in the provision of information on Zika and contraception services. ZIKV vector transmission was known but fewer participants were aware of risk of sexual transmission of Zika. Barriers to access healthcare services included contraceptive and PAC services included distance to healthcare facilities, disorganized admission process, long waiting times and out-of-pocket expenditure to purchase medicines. Furthermore, poor quality, mistreatment and abuse of women seeking PAC was prevalent. Some positive changes were noted over time, such as improvements in infrastructure including improved privacy and cleanliness, removal of fees, requisite to bring clean water to hospital.

CONCLUSIONS

Our results highlight the challenges and areas for improvement in policy and practice related to contraceptive services and PAC in the context of ZIKV infection. Public policies to prevent epidemics should focus more on providing proper sanitation; removing barriers to access and use of effective contraception as human rights priority. Zika epidemic has highlighted weaknesses in health systems that obstruct access to and use of sexual and reproductive health services. The study results call for increased efforts to improve access, especially for women of low socio-economic status and intervene at different levels to eradicate discrimination and improve equity in the provision of health care. Qualitative methods can capture the community perspectives and can provide useful information to develop interventions to improve services.

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.

The use of long-acting reversible contraceptives in Latin America and the Caribbean: current landscape and recommendations

STUDY QUESTION

Can the high rate and associated burden of unintended pregnancy (UP) and adolescent pregnancy in Latin America and the Caribbean (LAC) be reduced through wider access to and use of long-acting reversible contraceptive (LARC) methods?

SUMMARY ANSWER

Studies show that impoved access to and use of LARC methods is an effective tool for reducing the high rates of UP, unsafe abortion and abortion-related complications, and maternal deaths (as well as reducing their social and financial burden), and we have provided recommendations to help achieve this in LAC.

WHAT IS KNOWN ALREADY

LAC comprises 46 countries with 650 million inhabitants, and shows large disparities in socioeconomic development, access to health services and attention to sexual and reproductive health rights. The exercise of these rights and universal access to sexual and reproductive health (SRH) programmes is a key strategy for improving maternal health by reducing the number of UPs, the rate of women's and child mortality and morbidity, and the number of unsafe abortions. The implementation of SRH programmes in the region has contributed to a decrease in pregnancy rates of more than 50% over 40 years. However, despite this progress, the numbers of UP and adolescent pregnancies are still among the highest worldwide, which can be attributed in large part to the low prevalence of use of LARC methods.

STUDY DESIGN SIZE DURATION

This is a position paper with the objective of reviewing the magnitude and burden of UP in LAC, as well as available LARC methods and barriers to their access, with the goal of increasing knowledge and awareness among healthcare professionals (HCP), policymakers and the general public about the potential to reduce UP rates through the increased use of LARC.

PARTICIPANTS/MATERIALS SETTING METHOD

We searched the electronic databases of PubMed and EMBASE to identify studies published up to May 2017. We also searched for websites regarding LAC, LARC methods, and UP including, for example, those from the United Nations, the World Health Organization, Pan American Health Organization, the Alan Guttmacher Institute and the United States Agency for International Development. Studies were included if they investigated mainly UP and their consequences as well as the use of LARC methods in the region. During 3 days of meetings, the importance of the studies identified and the appropriateness of inclusion were discussed.

MAIN RESULTS AND THE ROLE OF CHANCE

LAC is not one unit and shows great ethnic diversity as well as economic and cultural differences among the various countries. These differences must be taken into account when developing policies related to disseminating information and combatting misinformation regarding the use of LARC among different audiences, such as adolescents and young women, nulligravidas, indigenous populations and women with disabilities. Furthermore, only some governments have made efforts to increase accessibility to LARC methods, and there is a need to implement training programmes for HCPs, launch education campaigns for the general public, increase access and review the cost-benefit analyses specific to LARC, which have already demonstrated that the upfront cost of LARC is less than the cummulative expense of short-term contraceptives. Recommendations to achieve these goals are presented.

LIMITATIONS REASONS FOR CAUTION

Knowledge and awareness of the contraceptive method itself and of the mix of individual countries in the region is essential to the development of specific strategies and actions, tailored to each particular country situation, aimed at increasing access to modern contraceptive methods, especially LARC.

WIDER IMPLICATIONS OF THE FINDINGS

Healthcare systems in LAC should consider LARC as a primary option for decreasing UP and adolescent pregnancy. Disseminating information, increasing awareness of their efficacy, removing barriers and improving access to LARC methods are the urgent actions recommended for government, academia, professional organizations, insurance companies and policymakers in order to address this major public health problem in LAC.

STUDY FUNDING/COMPETING INTERESTS

This manuscript was supported by a grant from the Americas Health Foundation (AHF), a 501(c)3 nonprofit organization dedicated to improving healthcare throughout the Latin American Region. LB and IM received additional support from the São Paulo Research Foundation (FAPESP) award # 2015/20504-9. The authors declare no conflict of interest.