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Why Zika is a huge Catch-22 for pregnant women

The World Health Organization has just declared the Zika virus to be a public health emergency. There's good reason to believe that Zika causes a severe birth defect called microcephaly, which is associated with abnormally small heads, underdeveloped brains, and reduced life expectancy. As rates of Zika infections have skyrocketed in Latin American countries, so have reports of these birth defects.

This is a terrifying prospect for pregnant women. But the scariest thing about Zika, especially for women in Latin America, might be the impossible web of Catch-22s it causes — due to both the nature of the virus itself and the restrictions that governments place on women's ability to prevent or plan their pregnancies.

Zika can easily go undetected, and doctors really don't know much about its risks to pregnant women

Only one in five people who get the virus show symptoms, which are typically pretty mild (like a flu with a rash) and don't require hospitalization.

Tests for Zika aren't widely available, and blood tests can only detect the virus itself up to a week after infection. Tests for antibodies can yield false positives if someone has a similar infection like dengue, yellow fever, or even just the yellow fever vaccine.

Still, there are a few things doctors are pretty confident about. The virus doesn't seem to stay in your system for more than about two weeks, and women who contract the virus early in pregnancy seem to be at greatest risk for microcephaly.

But there's also a ton of uncertainty. For one thing, the link between Zika and microcephaly hasn't even been definitively proven. It's strongly suspected based on circumstantial evidence, which is enough to issue public health warnings, but that's it.

Even if the link between Zika and microcephaly becomes certain, doctors have no idea how high the risk of birth defects actually is for pregnant women who have been infected. Will all pregnant women who are infected have a baby afflicted with some degree of microcephaly? Or is it more like half of pregnant women, or 10 percent, or 1 percent? What can a woman do to lower her risk? Doctors just don't know.

Right now, the only sure way for women in Zika-infested areas to avoid giving birth to a baby with microcephaly is not to get pregnant at all. And that's why many governments are recommending women put off getting pregnant for now. El Salvador went so far as to say that women should wait two years, until 2018, to try to have a baby.

The governments telling women not to get pregnant are really bad at helping women do that

It's a big thing under any circumstances to ask a woman to hold off getting pregnant when she's ready to start a family. For women in Latin America, the ask seems impossible. Most of these governments have already denied women any choice in the matter: Abortion is largely illegal, and contraception can be difficult to get.

Well over half (58 percent) of pregnancies in Latin America are unintended, partly because women don't have adequate access to contraception. Contraception is generally not covered even in countries with strong public health programs, and high poverty rates put it out of reach of many women. Birth control might be subject to legal restrictions like parental consent, and emergency contraception is sometimes outlawed. Schools in Zika-affected countries lack any comprehensive sex education. The programs that do provide education and services are often underfunded or undersupplied.

Gillian Kane, senior policy adviser at the global reproductive health nonprofit Ipas, remembers doing contraception consultation for youth in a public health clinic in Peru many years ago. "They'd give kids, like, two condoms for a month," she said. "It's not very realistic."

Sexual violence is also rampant in the region, and further compromises women's ability to control their fertility.

If a woman gets pregnant and doesn't want to stay pregnant, most Latin American countries severely restrict or ban abortion. Five countries — including El Salvador, which recommended that women don't get pregnant for two years — don't allow abortion under any circumstances, even to save a woman's life.

"By saying women need to postpone pregnancy, governments are really putting the burden on women," Kane said.

Women who get pregnant and have Zika have terrible options

This is true for most women who have unintended pregnancies in Latin America, but Zika puts a finer point on it. Women with Zika may need to end either a wanted or an unwanted pregnancy, but they don't have good options to do so.

In countries where abortion is severely restricted, fetal anomalies may or may not be covered as an exception. In countries like El Salvador where there are no exceptions, it doesn't matter. Abortion is prosecuted like murder, but without any lenience for self-defense.

That leaves most women with three basic, and unpleasant, options: Risk serious jail time, risk injury or death by having an unsafe illegal abortion (which sends about 760,000 Latin American women to the hospital every year), or risk having a child who will either die soon after birth or require constant care.

Especially in El Salvador, some women may not even get to make that choice. Right now, 17 Salvadoran women are in jail for up to 40 years for miscarriages or stillbirths that the state claims were really illegal abortions. Zika appears to increase the risk of miscarriage, which also increases the risk that a woman will be thrown in jail on suspicion of illegal abortion.

Even in countries where abortion is more readily available, women may face onerous restrictions like Uruguay's five-day waiting period. And even if abortion is accessible, the decision of whether to end a pregnancy due to Zika can be complicated.

Again, it's easy for a pregnant woman not to know she was infected with the virus in the first place. But even if she does, microcephaly often can't be diagnosed until very late in pregnancy, even in the third trimester. Depending on the local laws, fetal anomalies or health concerns for the pregnant woman may or may not allow having an abortion that late — or at all.

Microcephaly also has a range of outcomes. About 15 percent of babies born with microcephaly don't have any issues more serious than an unusually small head. Others have severe mental and physical disabilities. Most have a reduced life expectancy, and many die either before or shortly after birth. Each case is different.

"Countries need to inform people of the risks," Kane said. "And once they're informed, the final decision on what to do with the pregnancy is the woman's alone."

Women in the US could soon face similar dilemmas — and some of the same restrictions

The virus has already shown up in a few US cases. Outbreaks will probably be small and local, but officials are predicting that more outbreaks will happen, particularly in Gulf Coast states.

(Javier Zarracina/Vox)

But Gulf Coast states also offer some of the nation's worst access to reproductive health care, according to the Population Institute:

States with poor grades on their reproductive health "report card" have some of the same issues that Latin American countries do: high rates of unintended pregnancy, poor or inconsistent sex education, and significant financial or legal barriers to either contraception or abortion.

The barriers generally aren't as severe as they are in Latin America, but they still get in women's way — especially poor women. Abortion is still legal, but low-income women can't afford it if Medicaid isn't allowed to cover it. Emergency contraception is legal, but you might have trouble getting it in the emergency room. Contraception is covered under insurance, as long as you have insurance and as long as your insurance company doesn't arbitrarily flout the law and charge you anyway.

There's reason to believe that things could improve

Reproductive rights advocates are putting pressure on Latin American countries to liberalize their abortion laws in light of the huge public health threat Zika poses. They warn that deaths and injuries from unsafe abortions are likely to rise unless something changes.

Some are taking even more direct action. Women on Web offers online consultation and safe, mail-order medication abortion for women who live in countries where abortion is illegal. The organization recently announced that it will send the medication for free to women who have Zika and live in restrictive countries. The only exception is Brazil, which has been actively intercepting packages that contain abortion pills.

The United States may have a role to play as well, according to researchers at the Kaiser Family Foundation. The US government could boost family planning aid, although it can't help with abortion services due to the restrictions under the Helms amendment. The US could also use its public health expertise and diplomatic leverage to pressure countries into protecting the rights of women and girls.

US history also offers a window into how the debate over Zika and reproductive rights could play out in Latin America.

NPR reminds us that in the 1960s, rubella caused a similar panic among pregnant women to the one Zika is causing today. Rubella, also known as German measles, was responsible for 2,000 newborn deaths and 20,000 cases of congenital rubella syndrome, which causes deafness, heart problems, sight problems, microcephaly, and other issues.

National conversations about congenital rubella syndrome encouraged many Americans to feel more empathy for women who choose abortion — especially because white, middle-class, married women were speaking up about it. The demand for "therapeutic abortion" for pregnant women afflicted with rubella led California to legalize abortion in 1967. This helped open up the national conversation about abortion rights, leading to the 1973 Supreme Court ruling Roe v. Wade legalizing abortion nationwide.

It's hard to say whether Zika could help spark the same magnitude of change in Latin America, of course. The region is heavily Catholic, and has many other radically different social circumstances from the United States. But aided by the decades-long efforts of reproductive justice advocates in the region, it's a distinct possibility.

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