Whose responsibility is it to stop Zika? The largely mosquito-borne1 virus has spread to more than 20 countries and territories in the Americas since it arrived in Brazil about a year ago, and there’s concern that it’s threatening the fetuses of pregnant women. Zika’s symptoms for those infected are typically mild, but it has been linked to an increase in birth defects and neurological conditions. That has led officials to try to limit what women do in the affected regions.
In addition to declaring a “public health emergency of international concern,” the World Health Organization has said pregnant women should aggressively avoid getting bitten by mosquitoes. The U.S. Centers for Disease Control and Prevention, as well as the Public Health Agency of Canada and several European countries have issued advisories for pregnant women who are considering traveling to the majority of countries in Latin America and the Caribbean.
Several Latin American countries — including Brazil, Colombia, Ecuador, El Salvador and Jamaica — have made far more dramatic asks, saying women should delay getting pregnant altogether. History and experts say this is misguided; not only will officials’ requests fail to prevent the majority of pregnancies, they place the burden on society’s most vulnerable women. The numbers we have (and we don’t have perfect data) paint a relatively clear picture: For many women, pregnancy is not a choice.
Let’s begin with the basics: As is the case in the United States, plenty of women who get pregnant in Latin America and the Caribbean don’t intend to.2 The Guttmacher Institute, a policy and advocacy organization focused on reproductive health, estimates that 56 percent of pregnancies in Latin America — 62 percent in South America and 40 percent in Central America — are unwanted or mistimed. Although those numbers are already large, they mask much higher rates among certain groups. “These averages aren’t telling the fuller story,” said Jen Kates, who runs global health research for the Kaiser Family Foundation. Kates says women in rural areas, poor women, young women and victims of sexual violence have all been known to have even higher rates of pregnancies they didn’t plan.
These numbers are high in part because access to contraceptives varies greatly depending on where you are — and who you are. The United Nations Population Fund estimates that 11 percent of women in Latin America have an “unmet need for family planning,” which in reproductive health lingo means 11 percent of women married or in a union want to delay or prevent future pregnancies but aren’t using a method of contraception. That’s relatively low compared with other parts of the world, such as sub-Saharan Africa, where it’s 25 percent.3
Of course, it’s not just married women who get pregnant. Unmarried teenagers and single women aren’t always surveyed, but when they are, they also report high rates of unplanned pregnancy. Studies conducted over the past decade found that unmet need for sexually active but unmarried women ages 15 to 49 in most Latin American countries ranged from 32 percent to 55 percent, according to a review by the Guttmacher Institute. That suggests it’s harder for unmarried women to get contraceptives when they want them.
Cultural factors are part of the reason. “Some health workers are afraid they will promote sexual activity by bringing up the topic or offering contraception to teenagers,” said Dr. Guillermo Antonio Ortiz, who used to be chief of obstetrics at the National Women’s Hospital in El Salvador and now works in the U.S. for Ipas, an abortion advocacy organization. Others won’t provide contraceptives without permission from parents. But equally important, the kinds of contraceptives most commonly available aren’t necessarily the best methods for young women to prevent pregnancy. An injection every three months is the method most commonly available in government clinics, which service about 90 percent of the population.4 It’s harder to get pills, the method that more than 50 percent of sexually active female teenagers in the U.S. have used, according to Guttmacher. And although intrauterine devices have become more popular in the U.S., they are almost non-existent in government clinics in El Salvador, Ortiz said.
Ortiz says sex education is also extremely limited, particularly in rural and poor communities, meaning young men and women don’t know a lot about the options for preventing pregnancy.
This adds up to a lot of teenage pregnancy: Almost a third of babies born in El Salvador are born to teenagers.
In other words, the people who are being asked to avoid getting pregnant often lack the tools to do so. Which is why several international groups have not-so-quietly disagreed with the recommendation to delay pregnancy. “How are women supposed to follow a recommendation to delay pregnancy if they lack information and access to contraception?” Dr. Suzanne Serruya, director of the Pan American Health Organization’s Latin American Center for Perinatology, Women and Reproductive Health, wrote in Spanish on the organization’s website. “And if contraception fails, what are they supposed to do if they become pregnant?”
Serruya was referring to the very strict abortion laws in the region, which rarely allow women to choose an abortion except in cases of incest, rape or endangerment to the woman’s life. Some countries, including El Salvador, don’t allow abortions under any circumstance, and women there are regularly prosecuted for suspected abortions, even when there is clear evidence that a woman has suffered a miscarriage. Women who have been raped are allowed to have the morning-after pill (by prescription), but as in most countries, many women don’t report sexual assault. It’s hard to say what percentage of assaults go unreported, but we do know the percentage of women who have been abused is high. The country’s 2008 National Family Health Survey found that 13.4 percent of women ages 15 to 49 had been victims of sexual violence, and 7.8 percent had been raped.
Across the Americas, Zika has renewed conversations about whether laws around abortion need to change. Cases of microcephaly, a condition where the head is smaller than average, in Brazil kicked off a passionate debate over the country’s strict abortion laws. Although several conservative politicians had been trying to push through more restrictive policies around abortion before the Zika outbreak, some politicians are now pushing back, saying women with Zika should be allowed to have an abortion.
Even with less restrictive laws, though, the decision to have an abortion would be a complicated one under the circumstances presented by Zika. Microcephaly isn’t a health concern itself; it’s more often a symptom of an underlying problem and can occur in tandem with a range of more serious health issues. For some infants, it’s life-threatening. Others will have no associated health concerns. It isn’t generally detectable until late in the second trimester, and it’s often impossible to say how severe the problem is at that point. Abortions performed that late in pregnancy also require more specialized equipment and training than early-term abortions. Among the countries calling for women to delay pregnancy, Colombia allows for abortion in the case of any fetal abnormality, but that is rare in Latin America and the Caribbean. Regardless, any number of factors could go into the decision to have an abortion.
That includes deciding what to do when you’ve spent years preparing to get pregnant. In Brazil, people who used in vitro fertilization are struggling with the complicated question of whether to throw away the financial and emotional investment they have made so far trying to get pregnant. For older women, delaying a year or two could mean they risk losing the opportunity to get pregnant altogether.
El Salvador finally expanded its Zika interventions this week, nearly two weeks after asking women not to get pregnant. The government has said it will provide pregnant women with insect repellant and work on reducing the mosquito population. It doesn’t appear that those plans include anything to help women prevent unintended pregnancies.5
Finally, there’s the question of whether women need to fight Zika on their own. There has been very little policy that tries to involve men in delaying pregnancies in areas concerned about Zika transmission. As Anu Kumar, an executive vice president at Ipas, said, “Is it all immaculate conception that’s taking place? Why is this all directed at women?”