Zika: Rise in Abortion Requests Linked to Countries' Warnings

Marcia Frellick

June 23, 2016

Health warnings about the Zika virus significantly increased demand for abortions in Latin American countries, according to a study published online June 22 in the New England Journal of Medicine.

On November 17, 2015, the Pan American Health Organization (PAHO) issued a Zika alert in Latin America, and then several countries issued their own health alerts, including warnings to avoid pregnancy, cautions about microcephaly, and declarations of national emergency.

However, abortion is illegal or highly restricted in many Latin American countries, which leaves women with few options. One option is Women on Web (WoW), a nonprofit that provides access to abortion medications (mifepristone [also known as RU-486] and misoprostol) through online telemedicine in countries where safe abortion is not universally available.

To determine what, if any, effect the Zika warnings are having on requests for abortion medications, Abigail R. A. Aiken, MD, PhD, from the University of Texas at Austin, and colleagues analyzed WoW requests between January 1, 2010, and March 2, 2016, in 19 Latin American countries.

They used a regression-discontinuity design and assessed whether requests for abortion increased after the PAHO alert compared with numbers preannouncement. The authors included three control countries (Chile, Poland, and Uruguay), where researchers expected no increase in abortion requests related to the Zika virus.

Numbers Doubled in Three Countries

The researchers found a significant increase in requests to WoW from seven of eight countries that had active Zika transmission, a government warning, and legal restrictions on abortions. Requests to WoW more than doubled in Brazil and Ecuador (both saw a 108% increase) and almost doubled in Venezuela (93.3%), and increased by more than a third in most of the other countries (Colombia, Costa Rica, El Salvador, and Honduras). Only Jamaica did not show an increase among this group.

In contrast, the researchers saw no significant increase in requests from countries that had active Zika transmission and restrictions on abortion, but no national pregnancy advisory (Bolivia, Dominican Republic, Guatemala, Mexico, Nicaragua, Panama, and Paraguay).

Women were asked in the last weeks of the study whether they were seeking abortion because of concern about Zika infection. In their responses, women did not confirm whether they had received a diagnosis of a Zika infection.

"We cannot definitively attribute the rapid acceleration in requests in [the group where countries both issued health warnings and restrict abortions] to concern about Zika virus exposure," the authors write. "However, the percentage of women in each country who reported such concern as their reason for seeking abortion correlates with the observed country-specific increases in requests over baseline trends."

World Health Organization models predict that 3 million to 4 million people across the Americas (including North America, Central America, South America, and the Caribbean) will contract Zika through early 2017.

"Official information and advice about potential exposure to the Zika virus should be accompanied by efforts to ensure that all reproductive choices are safe, legal, and accessible," the authors conclude.

Numbers Underrepresent the Poor

Christine Curry, MD, an obstetrician-gynecologist in Miami, Florida, who is also affiliated with the University of Miami Hospital, agrees with the authors that the study likely underestimates the number of women seeking abortions, and she told Medscape Medical News the increase in abortion requests is not surprising.

"I think most of us had anticipated that the amalgamation of limited reproductive care access at baseline, limited access to abortions and all the uncertainties around Zika were pretty much guaranteed to increase the numbers of women seeking alternative sources of abortion," she said.

She said she found the numbers for women using the online method interesting. She added that WoW is a long-time, well-known source for easing access to first-trimester abortions globally, but that numbers using this source are only part of the story.

"Women who are accessing this version of abortion are women who are Internet savvy, who have a mailing address, and who have the ability to find these resources, so it probably underrepresents all the poorer women," she said.

It also does not account for the women who can pay their physicians enough to perform the procedure or get the medications from a local pharmacy, she notes.

Similar Requests in the United States

Dr Curry says she has also seen an increase in the number of women coming to Miami from other countries for Zika testing and asking for information about abortions. Those conversations are difficult because concrete information about risk factors with the virus is lacking.

When a woman screens positive for Zika, there is no defined percentage of risk. "I can't even give her that number to chew on," she said.

Also complicating the decision is that symptoms of the virus may not be visible on ultrasound until late stages of the pregnancy, a time when abortion is widely restricted or banned.

Warnings Not Enough

Dr Curry said this study indicated that women are hearing the warnings, but with little or no access to birth control, they are going to get pregnant, she added.

"I think the study suggests when they're being warned, they're responding and trying to not deliver unhealthy babies. But they're not able to do so legally within their own countries," she said.

Clearly, warnings are not enough, she and the authors agree.

Dr Curry points to the Zika Ethics Consultation document issued by PAHO.

It illuminates the imbalance in messaging when countries ask residents to avoid pregnancy for 2 years but then do not provide cheap or free access to contraception or do not provide the means to end a pregnancy.

"That's very much double-speak. You can't tell people not to do something and then not provide them the tools to help them achieve that goal," Dr Curry says.

The research was supported by the National Institutes of Health and the National Science Foundation. One coauthor is the founder and director of Women on Web, and three others are on the board of directors for the Women on Web Foundation or serve as a consultant for the organization. The remaining coauthor has disclosed no relevant financial relationships.

N Engl J Med. Published online June 22, 2016. Full text

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