In light of the Zika epidemic, is El Salvador ready to reconsider its prevailing anti-abortion law?

by Revathi Sahajpal, Nowrin Hoque, and Kiko Ho.

Abstract

Since 2015, the Zika virus has spread at an alarming rate throughout Latin America. The virus is primarily transferred through the bite of an infected Aedesmosquito, where perinatal and sexual routes of transmission are also possible. Infection during pregnancy is associated with birth defects including microcephaly and other severe neurological sequelae such as the Guillain-Barré syndrome. In response to the widespread Zika epidemic, the Ministry of Health of El Salvador issued a governmental advisory to “postpone pregnancy until 2018”. However, such a recommendation may be considered unrealistic given the current state of reproductive injus­tice in El Salvador. Not only are abortions illegal under all circumstances but also access to safe con­traceptives is limited. Lack of access to sexual and reproductive education, along with the country’s high rates of sexual violence and unin­tended teen pregnancies, further disadvantages young women in protecting themselves from the virus. 

Thisreview articleexamines the interac­tions between El Salvador’s absolute abortion ban and safeguarding maternal and child health during the Zika epidemic. The impact of such interactions will be examined with respect to the effect of Zika, both on the two main individuals concerned – the mother and the child – and on the rest of the house­hold with regard to health-related matters.Herein, we argue that the restrictive anti-abortion law is a barrier to managing the Zika epidemic effect­ively and propose alternative infection-control mea­sures that would be advisable. 

Introduction

Whenever a nation confronts a fast-spreading epi­demic with fatal consequences, a multifaceted strategy to controlling the outbreak is needed to minimize the spread of the infection. Appropriate interventions would include 1) educating the affected population on prevention, etiology and treatment; 2) providing access to high-quality preventive measures, diagnostics and drugs; and 3) maintaining efforts of vector control(1).

In the wake of the recent Zika epidemic, travel warn­ings and guidelines were issued towards the most vulnerable countries. Governments and health agencies in countries such as El Sal­vador, Colombia, Ecuador and Jamaica responded by advising women to postpone pregnancy until more evidence regarding the risks of Zika could be gath­ered. The present review article focuses on the govern­mental advisory issued by El Salvador, where such a delay in pregnancy was advised for up to two years. Despite the good intentions underlying that advice, it may yield consequences harmful to those concerned. 

This review article will describe barriers to successfully man­a­ging the Zika epidemic in El Salvador, in relation to the current state of “reproductive injustice” that is present. We will first examine the implications of the prevailing abortion ban on child and maternal health. Secondly, the financial impact of raising a Zika-infected child will be evaluated. We will then explore the motivations for issuing such a contro­versial advisory and how it has sparked public discus­sion of the prevailing policies that impede women’s rights with regard to human reproduction. Finally, we will discuss alternative efforts to contain the Zika epidemic, and we will compare El Salvador to Columbia where the relaxation of the abortion ban has been implemented in response to the Zika outbreak.

Background:The Zika Virus Epidemic

The Zika virus (ZIKV) is a flavivirus that is pri­marily transmitted to humans through the bite of infected Aedesmosquitos, and also by direct human-to-human transmission perinatally, sexually, throughbreastfeeding or through blood transfusion. In 2015 in Brazil, the largest Zika outbreak (so far) occurred and resulted in 440,000-1,300,000 sus­pected cases by the end of that year (6). The most noteworthy feature of this outbreak was the rise in the number of babies born with ZIKV-associated microcephaly, which is defined as the head-circumference at birth being lower than the 3^rdpercentile for gestational age and sex (10); by February 2016 more than 4000 such cases were reported. 

Since its emergence in Brazil, ZIKV infection has spread to more than 69 countries and territories in the Ameri­cas, Caribbean, Asia and the Pacific (6). In El Salvador, the first three cases of ZIKV oc­curred in 2015 (7). From 2016 to 2017, the highest incidence rates were in the regions Chala­tenango (341 cases per 100, 000 population), Cabañas (254 per 100, 000) and Cuscatlán (253 cases per 100, 000). In 2017, 297 suspected Zika cases were reported in El Salvador (7). 

In some cases, ZIKV infection is asymptomatic. In others, symptoms tend to appear within six to eleven days of infection (3). The general symptoms include maculopapular rash, subjective fever, red eyes, joint pain and headache. ZIKV infection has also been linked to increased risk for severe neurological sequelae, GBS, as well as meningoenceph­alitis and acute myelitis (2). The virus can be isolated from blood, urine, saliva, semen, amniotic fluid, and brain tissues (8). The infection can be diagnosed by the direct de­tec­tion of the virus and/or viral components or in­directly through the detection of antibodies produced in response to the ZIKV infection. 

In April 2016, the Center for Disease Control and Prevention (CDC) established a causal link between ZIKV infection during pregnancy and severe birth defects, primarily microcephaly. The risk of ZIKV associated microcephaly is 1 per 100 in the first tri­mester of pregnancy, but low to negligible there­after (3). 

No vaccine or antiviral drug against ZIKV in­fec­tion has yet been developed. Treatment aims at relieving symptoms. The fever and pain due to ZIKV infec­tion are treated with symptom-specific medi­cines like acetaminophen (Tylenol) (3).

Child health outcomes

Since October 2015, ZIKV has affected pregnancies in 29 countries. Its manifestations in children are dependent on the route of transmission (6). Peri­natal infectionoccurs when the mother acquires the virus two weeks before delivery and transmits it to the fetus during labor; this results in children ex­peri­­encing symptoms similar to those experienced in adults. Congenital infectionoccurs when a woman is infected earlier in her pregnancy and transmits ZIKV to the fetus. This can cause still- birth, miscarriages and/or a distinctive pattern of birth-defects amongst fetuses and infants (10,11). 

In February 2016, the World Health Organization (WHO), in view of the Zika epidemic in Brazil and the resulting cluster of microcephaly cases and other neuro­logical dis­orders, declared Zika a Pub­lic Health Emer­gency of International Concern (13). The WHO also began to issue statements about Con­genital Zika Syndrome (CZS) in this year (11). A Zika-Epidemiological Report for El Salvador was published in September 2017 by the Pan American Health Organization (PAHO) and WHO. It was based on the data published by El Salvador’s Ministry of Health and is still today the country’s most up-to-date publicly available relevant report. In this report, from Epidemiological Week (EW) 47 of 2015 to EW 33 of 2017, a total of 391 preg­nan­cies with suspected ZIKV infection had been re­ported (7); that between EW 46 of 2015 and EW 5 of 2017, 313 cases of GBS, including four deaths, had occurred; that as of EW 31 of 2016, 109 cases of microcephaly had been reported, including four cases associated with laboratory-confirmed ZIKV infection; and that as of EW 35 of 2017, no deaths due to Zika had been reported by the El Salvador Health authorities (7). 

Maternal outcomes

While the effects of ZIKV infection can be fatal for the child, an infected pregnant mother experiences psychological as well as physical distress. Psy­cho­logical dis­tress can be caused by fear of miscar­riage as well as by fear of CZS (14); and, because abor­tion is illegal in El Salvador, an unintended or unex­pected mis­carriage may put a women at risk of criminal charges (15). 

A pregnant woman infected with the virus who wishes to terminate the pregnancy in order to avoid having a child with fatal birth defects may thus choose to opt for an unsafe, “back-alley” abortion. These tend to pose several threats to a woman’s health, including hemorrhage and risk of sepsis (16). After PAHO declared Zika a health emergency in Latin America in November 2015, online requests for abortion medications increased for most of the affected countries, demonstrating women’s desire to terminate their pregnancies despite the risks (17).

Among Latin American countries, El Salvador has the highest rate of unintended adoles­cent pregnancy and femicide: amongstthe women surveyed in El-Salvador between 1996-2013, 12.5% reported having experienced sexual and/or other physical violence. Despite this, the abortion-ban has continued (18). Given this reality, a woman’s choice to abstain from sex to delay pregnancy, in wake of the Zika outbreak, may not be respected, particularly when limited access to contraceptive measures complicates matters even more.  

Early childbearing can lead to a higher risk of maternal death and physical impairment, and is asso­ci­ated with poverty and the inability of these young mothers to attain higher education (19). In 2013, when compared to countries with liberal abortion policies, countries with restrictive abortion policies had three times higher average adolescent and higher unsafe abortion and total fertility rates (19).  Also, countries with restric­tive abortion policies had an average maternal mor­tal­ity ratio of 223 maternal deaths per 100,000 live births, whereas countries with liberal abortion poli­cies had 77 maternal deaths per 100,000 live births (18). As such, ZIKV compromises maternal health more significantly in countries where restrictive abortion policies are present.  

 The psychological impact of raising a severely disabled child is all the more notable if the mother does not have access to affordable medical care(20). A child stricken with CZS may require, at the onset, multiple imaging tests to con­firm the diagnosis. During this time, the uncertainty of the diagnosis may cause great dis­tress in the family. If the diagnosis is confirmed, the mother may feel guilty about not having done enough to protect against mosquito bites during her pregnancy (20). 

Ifit is the case thata country’s public-health sys­tem offers services to affected families, parents sometimes have to travel hundreds of miles to take their sick children for treatment (21). It is likely to be very stressful and challenging for parents to take care of such children. Excessive fatigue can lead to depression and anxiety in parents (22).

Financial and household outcomes

Employed mothers of such children are likely to have to give up such em­ployment and dedicate themselves entirely to caring for their child, thus reducing household income (21). It has been shown in Brazil that microcephaly cases are more prevalent in low-income than in high-income families (23). The extra expenditures involved in caring for the affected children can thus exacerbate notably the financial situation of these families. They not only are more susceptible (than affluent families) to ZIKV, but also face a heavier financial burden as they often cannot pay for the necessary support and care (24). 

Whereas the national average monthly household income in El Salvador is equivalent to $540 (in cities it is equivalent to $640; in rural areas, to $357; see apropos Figure 1), the total lifetime monetary costs of each microcephaly case in El Salvador is estim­ated to exceed $700,000 (23, 24). The exact estimates break down, given an assumed life-expectancy of 70 years for individuals with microcephaly, to more than $870 per month (see Table 1) (24). This is much more than the average income of urban families,and more than twice the average incomefor rural families. 

In ZIKV-affected countries, the mothers of these sick babies may abandon their other children to give their full atten­tion to the sick child(20). Moreover, it is not un­common for husbands to abandon their wives with such sick children. Such mothers receive very little financial support from out­side the family (21). For children with severe disabilities, they and their families often confront social discrimina­tion. Some mo­thers have stated that they hide the heads of their children with microcephaly to avoid stares and ques­tions by the community (25). Furthermore, full-time caregiving greatly reduces the opportunities for normal social experiences for parents. By devoting themselves exclusively to the needs of the sick child, these families are particularly vulnerable to social isolation (20).

Table 1: Per-case lifetime costs of microcephaly in El Salvador.

Reference: A Socio-Economic Impact Assessment Of The Zika Virus In Latin America And The Caribbean: With a focus on Brazil, Colombia and Suriname (pp. 1-92, Rep.). (2017). New York: United Nations Development Programme.

Figure 1: Average monthly household income in El Salvador (in US$) in 2014

Preventive Intervention Strategy

In order to reduce the spread of ZIKV and to minimise the number of microcephaly-afflicted newborns, El Salvador’s Ministry of Health has advised women to postpone pregnancy for up to two years, in addition to setting place certain vector-control measures. However, there is a particular issue in place: a Penal Code wasimposed in 1998 that includes an anti-abortion law. The law is described as follows:  

“Aperson who performs abortion with the woman’s consent, or a woman who self-induces or consents to some­one else inducing her abortion, can be imprisoned for two to eight years. A person who performs an abortion to which the woman has not consented can be sentenced to four to ten years in jail; if the per­son is a physician, pharmacist, or other health care worker, he or she is instead subject to between six and twelve years.”(27)

Relatedly, under the influence of the Christian Democratic party, El-Salvador amended its constitution in January 1999 to recognise human life from the moment of conception (27).

Currently, in light of the Zika epidemic, the necessity of this prevention strategy is questioned by El Salvadorian women and the ongoing debate onamending the country’sabortion-ban is heating up (1).

Challenges to Intervention Strategy 

It is often challenging for women in El Salvador to delay, and even prevent, pregnancies for various reasons. Firstly, there are high rates of sexual violence that commonly lead to unintended pregnancies (24). Moreover, El Salvador has the highest adolescent pregnancy rate in Latin America,accounting for approximately 32% of all births, ac­cord­ing to the Ministry of Health (28). Adoles­cent girls are particularly vulnerable to un­planned preg­nancy since they may face discrimination for access­ing to contraceptive and family-planning services. This situation is the worst among low-income groups, where the coverage of family plan­ning services is especially low and the rate of un­intended teenage pregnancies are high. The United Nations Population Fund has estimated that unin­tended pregnancies would de­crease by some 65% if the need for contraceptives were met (26). Further­more, since the rate of sexual vio­lence in El Salvador ishigh; two-thirds of the victims are less than 15 years old; and an unwanted pregnancy can result from rape. Given the high incidence of unplanned pregnancies, sexual violence, and difficulty in accessing reproductive and sexual health-services, there is concern that women may be unable to comply with the governmental recom­mendation to wait for two years before risking pregnancy (24).

The absolute anti-abortion ban was enacted without any public consultation (24). This law allows no excep­tions, not even in the circumstances of rape, the mo­ther’s life being endangered, or the fetus being severely deformed. As such, a ZIKV-infected fetus is not an exception to this law, and both maternal and child health may be compromised. The Salvadorian Citizens’ Group for the Decriminalization of Abortion arguesthat the illegalization of abortion putsthe well-being of thousands of women and girls at risk. Many young women are afraid to seek medical help or even to talk about their concerns during preg­nancy. Between 2000and 2004, 250 women were reported to the police for doing so. Among those 250 women, 147 were prosecuted and 49 imprisoned – 23 of them were charged for abortion and 26 of them were charged for murder– with sentences of up to 50 years (27). Most of these women were young, poor and single, and were reported to police by public hospitals. 

According to government data, suicide is the cause of some 60% of the deaths of pregnant girls between 10 and 19 years old (28). For example, a19-year-old woman who had becomepregnant as a result of rape was sentenced to 30 years of impris­onment for “aggravated homicide” after having received emergency obstetric treatment during delivery (29). She suffered a spontaneous obstetric complication which resulted in a stillbirth. She was charged with manslaughter, i.e. of intentionally fail­ing to save the baby. When she was at the hospital, she was not allowed to speak with her family, and she was not able to hire a lawyer (27). 

Theprevalence of criminal violence in El Salva­dor puts remark­able pressure on the judicial system. Becauseprosecutinga gang-member willlikely to entail threats of violence from the gang,prosecutors are more likely to prosecute women seeking abortion, many of whom haveno money to hire a defense attorney, noway to threaten pro­secutors, and can readily be arrested while re­cover­ing in hospital from an obstetrical emer­gency (30). The criminalization of abortion thus not only leads to women toseekunsafe abortions, but also incitesanxiety in women who experience miscar­riage or other obstetric complications (29).

Alternative Efforts to Avoid Infection with Zika

We argue that alternatives to the  delay-pregnancy recommendation would prove more effective in controlling the spread of ZIKV. Current alternative efforts proposed by public health officials include vector control, sexual/reproductive health education and services, as well as improved diagnostics (1).Aedes aegyptimosquitoes often breed and live in or around people’s living area. This supports the notion that local communities are crucial in the execution of Zika prevention. The El-Salvadorian government should provide education on vector-control strategies such as removing standing water, where mosquitoes lay eggs, and by holding insecticide-spraying campaigns (24). How­ever, since Zika can also be spread via sexual trans­mission, it is important that the government provide sexual and reproductive health services and educa­tion at primary- and secondary-school level. This inclu­des providing information and access to safe contraceptives. Such services could reduce a great deal of unplanned pregnancies, espe­cially among teenagers (27). 

Proper laboratory diagnostic testing of Zika is usually in­ac­cessible in El Salvador (26). It is often diffi­cult to detect the disease since most of the infected individuals are asymptomatic (only some 20% of them have noticeable symptoms.) It is essential for the country to have diagnostic tools available to reduce human-to-human transmission and to prevent the long-term consequences of Zika (25). Less strict anti-abortion legislation is also needed. The latest WHO report in 2017 on Zika shows that Brazil has reported 2211 cases of microcephaly, whereas Colombia has only reported only 60. Some experts have suggested that this difference between Brazil and Colom­bia may be due to the less restrictive anti-abortion laws in the latter country (31). In 2015, health officials in Columbia agreed to accept Zika infection as a rationale for legal abortions. By relaxing the anti-abortion ban, this reduced Zika-associated microcephaly cases to 47, whereas 700 cases had been predicted (1).

Future Implications

Given the existing laws and policies that limit access to contraception and abortion in El Salvador, the issued advisory in face of the Zika epidemic is a challenging guideline to follow. Many women have little authority in their house­hold and are unable to participate in decisions regarding their own sexual behavior. Multisectoral interventions are essential to protect maternal and pediatric health. In accordance with WHO recom­mendations, access to health interventions and ser­vices should include family planning, contraception, safe abortion, appropriate care for high risk preg­nan­cies, psycho-social support, gender-based vio­lence-prevention programs, and sex education (32). It is crucial to ensure enhanced delivery of such services and to reduce bar­riers to accessing quality diag­nostics and drugs. Currently, a 24-monthlongstudy is monitoring the current trends of contraception and abortiondemands in ZIKV-affected areas(33). This is achieved through the development of a sur­veillance sentinel-site net­work, where sentinel sites will begin in El Salvador and Columbia (33). The WHO has recommended that countries adopt this monitoring approach in order to inform policy-makers to help build the infra­structure needed to meet the growing demand for these services. This will strengthen the health system response to community needs in sexual and reproductive health.

Conclusion

The Zika epidemic has paved the way for a much-needed discussion regarding the current state of reproductive injustice in El-Salvador. The Ministry of Health has issued a contro­versial ad­visory that women should delay preg­nancy for up to two years. This form of infection-containment effort dimin­ishes the re­pro­ductive rights of women in El Salvador given the strict anti-abortion legislation that is currently operative there. There are three main ways in which those rights are there­by limited:1) thegovernmentalapproach does not considerintersection of gender and poverty, where it disregards the needs of poverty-stricken women. Indeed, the effect of an epidemic is generally more likely to be pronounced for the poor because of their limited purchasing power, their often unsanitary living condi­tions and their relatively limited ac­cess to healthcare; 2) this recommendationalsoignores the prevalence in the region of gender-based vio­lence whereby women are often subjected to unwanted pregnancies in the case of rape; and 3) the recommendation ig­nores the lack of ac­cess to contra­ception and safe abortion. 

Due to this myopic public-health response by the government, Zika infection in El Salvador has significantly impacted maternal mortality and child morbidity. An increase in illegal and unsafe abortions continues. And yet, an in­crease in the rates of microcephaly and other develop­mental disorders in children may not effectively be prevented (34). This articleis an effort to provide compelling evidence to support the need to decriminalise abortion in El-Salvador in order to safeguard maternal and child health in the foreseeable future.

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