By Wendy Anson, Ph.D.
Photo: Talita Santos da Silva, 21, at home in Recife, Pernambuco State, Brazil.
Credit: PAHO/WHO—Harold Ruiz
“We set out to do this study because we knew we had the only reliable information on both the spread of Zika and the rising number of requested abortions in Latin America,” explained Dr. James Trussell, faculty at Princeton University’s Office of Population Research (OPR), which was awarded a population center grant from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) to undertake the timely investigation.
“Ours was the only data in existence that could provide the look into the past that the regression-discontinuity analysis needed,” said Trussell.
Spread through the bite of an infected Aedes mosquito or by way of sexual relations with an infected male, the Zika virus has raised worldwide concern among pregnant women and their significant others. Zika infection during pregnancy or at delivery can cause congenital abnormalities, among them microcephaly, a birth defect where a baby’s head is smaller than average, and where the baby has substantial developmental delays and intellectual disabilities.
In February 2016, the World Health Organization issued a Public Health Emergency of International Concern in response to the Zika outbreaks in the Americas and reports of birth defects in those regions. While some of the Latin American countries remained silent, other nations in the affected areas responded with health advisories declaring national emergency, alerts about microcephaly, and warnings for women to avoid pregnancy. Yet in the silent and the advisory-issuing nations alike, termination of pregnancy was illegal.
“One might wonder as we did, what about the women who are already pregnant?” said Trussell.
For the past few years, one option for Latin American women seeking abortions outside the formal health care setting has been the online Women on Web (WoW), a nonprofit providing access to abortion medications (mifepristone and misoprostol) to women internationally.
Women can access the WoW website in Spanish, Portuguese, French, English, and Polish, which together constitute the first language of over 95 percent of women in the Americas. WoW refers women with an unwanted pregnancy of up to 9 weeks to a doctor. If medical criteria are met, the physician prescribes the mifepristone and misoprostol, which are sent by a partner organization. Real-time instruction and follow-up are emailed by a trained, multilingual helpdesk team.
To see whether or not the government-generated anti-pregnancy warnings had an effect on the numbers of requests for abortions, Dr. Abigail Aiken, the study's principal investigator – also working at Princeton’s Office of Population Research – and her colleagues, including Trussell, set up Groups A, B, and C. The groups were formulated to facilitate calculation of the number of online requests for abortion medication from WoW between January 1, 2010 (defined as the “before-Zika” period), and November 17, 2015, onward (as the date of the first public alert about the virus issued by an international health organization).
- Group A (8 Latin American countries) had confirmed autochthonous (local) Zika transmission, no legally available safe abortion, and issuing of a public health advisory to pregnant women due to the risk of Zika;
- Group B (4 Latin American countries) had no confirmed autochthonous Zika transmission and no legally available safe abortions; and
- Group C (7 Latin American countries) had confirmed autochthonous Zika transmission, no legally available safe abortion, and no advisory from the government.
- Chile, Uruguay, and Poland were used as controls.
To test whether the rate of requests increased contemporaneously with the spread of the Zika, the team used a regression-discontinuity design, a non-experimental approach that compares observations (in this case, time series of abortion requests) lying closely on either side of a cut point.
In all Group A countries, except Jamaica, there were statistically significant increases of 36 percent to 108 percent over baseline in requests for abortion through WoW.
Aiken, Trussell, and the team dispatched a letter to the editor of the New England Journal of Medicine (June 2016) reporting that the number of pregnant women requesting abortions had significantly increased in certain Latin American countries that had issued Zika-specific health advisories and/or warnings urging women to avoid pregnancy. Given that abortion is illegal or highly restricted in most Latin American countries, the finding that a significant number of potentially infected Latin American pregnant women were seeking to abort pregnancies was noteworthy.
Aiken and her group allowed that they could not account in their sample for women living in remote areas without internet access and did not go on in the article to specify the nature, type, and intensity of advisory messages broadcast within each country. However, the study was clear that in Latin American countries that issued information about the Zika virus and pregnancy, women heard the alerts and attended the message; requests for abortion through WoW increased significantly. The investigators also pointed out that their method may have actually underestimated the incidence of abortions, since many women, concerned by the warnings, may have used an unsafe method to attempt termination of pregnancy.
“It’s not very hard to extrapolate this situation to the U.S.,” Trussell affirmed.” “It’s not unlikely that there’s going to be a Zika epidemic in the U.S.; we haven’t seen anything thus far because the mosquitoes haven’t come out yet.”
“As a matter of fact, the Lancet just published a paper today that finds there are many babies born to Zika-affected mothers who appear to be normal, with normal-size heads, but there is clear evidence of brain damage that we are just starting to see now,” Trussell continued.
Aiken’s study looked at 28,670 requests for help. According to models developed by the World Health Organization, 3 to 4 million people across the Americas (including North America, Central America, South America, and the Caribbean) will be infected with the Zika through early 2017. As Aiken reminds, a substantial number of these countries wherein millions stand to contract the virus—and many thousands will become pregnant while Zika-infected—are those countries in which access to safe termination of pregnancy is not an option.
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Requests for Abortion in Latin America Related to Concern about Zika Virus Exposure
