Zika Virus: The Challenge for Women

The recent and rapid spread of Zika virus, a mosquito-transmitted infection, into the Americas is the latest in a series of emerging infectious diseases that pose new threats to human health. Active Zika transmission is now reported in over 20 countries in Latin America and the Caribbean, as well as several other territories, and the World Health Organization (WHO) predicts it could affect 4 million people across the Americas this year alone. On February 1 following an emergency meeting of experts, WHO declared that clusters of birth defects associated with Zika infection during pregnancy constitute a “public health emergency of international concern” requiring a stepped up, coordinated global response. In April the Centers for Disease Control and Prevention (CDC) confirmed this link.

Even before the association between Zika infection and births defects was confirmed, the Pan American Health Organization (PAHO), the CDC and other health authorities had issued guidance to pregnant women and those seeking to become pregnant to consider delaying travel to Zika-affected areas, and for those living in countries with widespread Zika transmission to avoid exposure to mosquito bites. In some countries public health authorities have gone even further, recommending that women postpone becoming pregnant for a period of time; most notably, the Minister of Health of El Salvador, a country which is experiencing a rise in suspected Zika cases, has recommended delaying pregnancy until 2018.

Such calls to postpone pregnancy raise serious issues, because many women across the region have limited access to contraceptives and other reproductive health services, experience high rates of sexual violence, and face other reproductive health decision-making barriers that can result in unintended pregnancies. In fact, some of the Zika-affected countries have among the strictest abortion laws in the world, potentially presenting women who have an unintended pregnancy with a dangerous catch-22. The United States government may have an important role to play in addressing health access and rights for women in Zika-affected countries, both through its direct health and development assets as well as its diplomatic engagement and public health expertise. To understand more about where these issues are likely to be more acute, we examine available country-level data on access to contraception, abortion policies, and the US government’s foreign assistance and global health presence in Zika-affected countries.

Access to Reproductive Health Services in Zika-Affected Countries

One way to measure access to reproductive health services is to look at the use of contraceptives, as indicated by the contraceptive prevalence rate (CPR). As shown in Table 1, of the 21 countries in Latin America and the Caribbean with confirmed Zika transmission as of April 14, the CPR (for any method of birth control) ranges from just 37.8% in Haiti to 79.5% in Nicaragua; for modern methods, which are more effective, the range is 33.6% in Haiti to 75.7% in Costa Rica. Most countries in the region have a CPR for modern methods below 70%, including 5 countries with a CPR at 50% or below. It is important to note that these CPR estimates are national averages that likely mask significant inequities within counties, particularly across geographic and income lines. Typically, poorer women and women in rural areas have much less access to contraceptives, and are likely to be most at risk for Zika infection as well. In addition, such averages do not take into account the contraceptive method mix available to women, which in some cases may be limited.

Another way to gauge access is to examine contraceptive security, reflected by whether stock-outs (lack of availability) of contraceptive commodities have occurred in a country. Data on such measures (not shown in table) are available for seven of the 21 countries with widespread Zika transmission in the region – the Dominican Republic, El Salvador, Guatemala, Haiti, Honduras, Nicaragua and Paraguay. Of these, all but Nicaragua and Paraguay report that in 2015, contraceptive commodity stockouts were a problem at either the service delivery point level or central level, indicating ongoing issues with access.

For those women who face an unintended pregnancy and pregnant women concerned they have been exposed to Zika virus, their options may be quite limited. There currently is no vaccine or treatment for Zika virus and microcephaly, a lifelong condition, has no cure or treatment. Looking at the abortion laws of these countries, nine have among either the most restrictive or highly restrictive abortion laws in the world. Three (the Dominican Republic, El Salvador, and Nicaragua) provide no legal access to abortion under any circumstances. Six (Guatemala, Haiti, Honduras, Paraguay, Suriname, and Venezuela) provide access to abortion only to save a woman’s life. At present, microcephaly isn’t detectable until quite late in pregnancy (if at all), when many countries, even those with less restrictive abortion laws, would not permit an abortion. In eight of the nine countries with severe restrictions, the CPR for modern methods is below 70%; three of the countries have a CPR of 50% or below. Five of the nine reported stockouts of contraceptives, meaning that contraceptive access may be more problematic for women in these countries.

U.S. Bilateral Presence in the Region

The U.S. government has limited bilateral assets in the region, a reflection of the longer term “graduation” of many Latin American countries from U.S. development assistance over the last several decades as they have grown economically and seen improved health outcomes. Indeed, with the exception of Haiti all of the Zika-affected countries in the region are designated either as high income (4 countries) or middle income (16 countries). As shown in Table 2, of the 21 countries with ongoing Zika transmission, six receive some bilateral funding for health from the U.S. Other than Haiti, funding was less than $25 million in 2015. Two receive funding for family planning/reproductive health (FP/RH) and maternal and child health (MCH) programs specifically – Guatemala and Haiti – though this funding was under $20 million in each country in 2015. Haiti, the poorest country in the region, has the biggest U.S. global health presence, with funding in four program areas (HIV, FP/RH, MCH, and nutrition) totaling over $137 million, primarily for HIV. Twelve other countries receive U.S. development assistance in non-health sectors, while three receive no U.S. development assistance.

Implications for the U.S.

Taken together these data suggest that women in Latin America and the Caribbean, particularly those who are poorer and live in rural areas and especially those countries with limited contraceptive access and evidence of some contraceptive commodity stockouts may face significant barriers in delaying pregnancy as recommended by some public health authorities, and if they experience an unintended pregnancy or have concerns about being infected with Zika during their pregnancy, have limited options. The U.S. government may have an important role to play in addressing these challenges. While its global health assets in these countries are limited, where such assets are present, the USG could help to augment access to family planning commodities and other services. Where direct assets are not present, the U.S. could consider mobilizing additional resources where access may be a problem. Ultimately, though, given its limited health and development presence in Zika-affected countries, the U.S. government may be best positioned to use its public health expertise and diplomatic leverage, including through supporting the WHO and other UN mechanisms, to ensure that the rights of women and girls are protected as countries seek to respond to the spread of Zika virus. Indeed, a key principle of U.S. family planning assistance is “voluntarism and informed choice”, to ensure that people can choose voluntarily whether to use family planning, have information on their child-bearing choices, and are offered a broad range of methods and services, a principle critical to ensuring that women are able to make their own reproductive health decisions. The U.S. also has public health and research expertise to contribute to the global effort to identify diagnostics, treatments, and a vaccine for Zika and to continue to investigate the the virus and its health effects.

The White House recently brought federal health and national security officials together to discuss Zika and some members of Congress have begun calling on the Administration to do more. Now that the World Health Organization has declared Zika due to its potential link to microcephaly a “Public Health Emergency of International Concern”, there will be intensified attention to these issues. As the U.S. and global responses unfold, we will learn more about this threat, and understand better the kinds of interventions that will be most effective in addressing the Zika threat. Based on our best understanding right now, ensuring women’s access to contraception and broader range of reproductive health services is a key part of the ongoing response.

Table 1. Contraceptive Prevalence Rates (CPR) and Abortion Policies in Latin America and Caribbean Countries with Active Zika Transmission
Country CPR – Any Method CPR – Modern Methods Abortion Policy
Barbados 60.3 56.7 Some restrictions
Bolivia 62.5 40.4 Some restrictions
Brazil 79.0 75.2 Restrictive
Colombia 78.2 71.7 Some restrictions
Costa Rica 78.9 75.7 Restrictive
Cuba 73.6 72.3 Least Restrictive
Dominican Republic 71.8 68.6 Most restrictive
Ecuador 72.6 61.2 Restrictive
El Salvador 70.7 64.3 Most restrictive
Guatemala 57.2 47.8 Highly restrictive
Guyana 44.8 43.5 Least restrictive
Haiti 37.8 33.6 Highly restrictive
Honduras 72.7 63.7 Highly restrictive
Jamaica 71.8 67.9 Restrictive
Mexico 72.6 67.4 Least restrictive
Nicaragua 79.5 75.4 Most restrictive
Panama 61.3 57.7 Some restrictions
Paraguay 77.4 68.0 Highly restrictive
Suriname 51.8 50.8 Highly restrictive
Trinidad and Tobago 50.0 43.8 Restrictive
Venezuela 70.0 63.8 Highly restrictive

“-” = No data available
Abortion Policy = circumstances under which a woman can legally get an abortion in that country
     “Most restrictive” = no abortions under any circumstances
     “Highly restrictive” = only to save a woman’s life
     “Restrictive” = only to save a woman’s life, due to rape or incest, and/or to preserve a woman’s mental or physical health
     “Some restrictions” = only  for one of the following reasons: economic, social, fetal impairment, rape, incest, woman’s mental or physical health, or to save a woman’s life
     “Least restrictive” = abortion legal (typically up to a certain gestational age such as 20 weeks)

Pan American Health Organization, Countries and territories with autochthonous transmission.
United Nations Population Division, Estimates and Projections of Family Planning Indicators 2015.
United Nations Population Division, World Abortion Policies 2013.

Table 2. Presence of U.S. Government Global Health and Other Foreign Assistance in Latin American and Caribbean Countries with Active Zika Transmission, FY 2015
Country US Global Health Funding by Program Area Other US Foreign Assistance Program
Family Planning/ Reproductive Health HIV/AIDS Maternal and Child Health Nutrition
Barbados   $22,281,000      
Brazil   $300,000      
Colombia         X
Costa Rica X
Cuba X
Dominican Republic   $15,113,000      
El Salvador         X
Guatemala $6,500,000 $3,000,000 $8,700,000  
Guyana   $6,636,000      
Haiti $9,000,000 $104,013,000 $14,000,000 $10,200,000  
Honduras         X
Jamaica X
Mexico         X
Nicaragua         X
Paraguay         X
Suriname         X
Trinidad and Tobago
Venezuela         X
SOURCE: Kaiser Family Foundation analysis of data from the U.S. Foreign Assistance Dashboard [website] available at www.foreignassistance.gov

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