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PORT-AU-PRINCE, Haiti — As Zika spreads, many Latin American officials, concerned the virus is tied to a surge of birth defects, are repeating an ominous warning to women: Don’t get pregnant until the epidemic is over.

But that advice, repeated from Colombia to the US territory of Puerto Rico, is exposing a major vulnerability in health care systems across the Americas: Millions of women lack access to the medical care and education they need to control when they get pregnant.

“It isn’t fair to say ‘don’t get pregnant’ when there is no sexual education program in schools,” said Dr. Guillermo Antonio Ortiz, the former chief of obstetrics at the National Women’s Hospital in El Salvador — a country whose health ministry recently urged women to wait two years before conceiving.


Ortiz, who is now a senior health system advisor for Ipas, a US-based nonprofit that promotes access to abortion and reproductive health services, said that as many as 90 percent of pregnancies in El Salvador are unplanned. “The government,” he said, “has a responsibility to not just advise against pregnancy, but also make sure there is safe and modern contraception available.”

The warnings have been prompted by concern that Zika is causing a surge in a birth defect known as microcephaly, a condition in which babies are born with small heads and underdeveloped brains. Brazil has seen an explosion of reported cases, and the US Centers for Disease Control and Prevention has urged pregnant women to avoid traveling to two dozen countries and territories where there is active transmission of Zika.


Fear travels faster than science, and public health officials caution that a link between Zika and microcephaly has not been definitively established. There is also uncertainty over how many cases of microcephaly have occurred in Brazil and how the rates compare to years before the viral outbreak began.

Officially, there have been 125 suspected cases of Zika in Haiti since the virus was first confirmed here two weeks ago. Unofficially, it’s everywhere. In the crowded capital, Port-au-Prince, it seems everyone knows someone who has had the telltale rash, low-grade fever, and reddened eyes that can come with the infection.

Venus Hamel, a 28-year-old nurse at a hospital in Carrefour, on the outskirts of Port-au-Prince, said the disease is rampant in the city’s shantytowns, where people are unable to protect themselves from mosquito bites and have not been informed about the potential implications for pregnant women.

“It’s more complicated than chikungunya,” another mosquito-borne disease that arrived in the Caribbean two years ago and spread quickly through Haiti, “and chikungunya did a lot of damage,” Hamel said.

Zika virus, which can be transmitted by mosquitos, has exploded onto the world stage. Alex Hogan/STAT

Benita Louis, a 29-year-old from Léogâne, the town at the epicenter of the 2010 earthquake, is pregnant with her first child. Louis said she was unable to afford prenatal checkups and had never heard of Zika before. Even if she had, it would be difficult to avoid mosquitos in her hometown on the coast of Haiti’s southern peninsula, or during the 18-mile trip she regularly makes to visit family in a Port-au-Prince slum, riding in open-air group taxis known as tap taps.

Her baby is due in March. “God will be there for me,” Louis said.

In Haiti, estimates of the number of married women who want to delay or prevent pregnancy but who do not have access to birth control reach as high as 37 percent. The United Nations estimates that across the Caribbean, that figure is 20 percent, and 13 percent in Central America.

The figures are almost certainly higher for unmarried women, and don’t account for limited access and use of contraception among men responsible for impregnating them.

If more people choose to follow the warnings about Zika and delay having children because of the epidemic, the percentage of people who want birth control but can’t access it is bound to be even higher, said Amanda Klasing, a senior researcher in the women’s rights division at Human Rights Watch who is studying the issues around the current outbreak.

“I think the responses that you’ve seen coming out of ministries are a reflection of the fact that women’s health and reproduction rights issues are not integrated at every level of public health responses,” Klasing added.

If a link between Zika and serious birth defects is definitively established, the public health issues could become even thornier.

Many Latin American countries have large Roman Catholic populations and some of the world’s most restrictive anti-abortion laws. El Salvador, Nicaragua, and the Dominican Republic, all of which are experiencing Zika outbreaks, ban abortion entirely, with no exceptions for victims of sexual violence or the health of the fetus or the mother. (Similar laws exist in Chile, but that country is unlikely to be affected because it, like most of the United States, is outside of the Aedes aegypti mosquito’s current range.)

Women who terminate pregnancies in El Salvador can face murder charges and prison sentences of up to 40 years. Just weeks ago, in December, the Dominican Republic’s Constitutional Court struck down a law that would have decriminalized abortions when done to save a pregnant woman’s life.

Other countries, including Colombia and Brazil, allow pregnancies to be terminated only in isolated cases.

One judge in Brazil, which has the world’s largest Catholic population, has said he would be willing to allow abortions in some cases of microcephaly, the BBC reported. Colombians are also debating increasing access to abortions in light of the epidemic. Hundreds of thousands across the region are injured in clandestine abortions each year across Latin America, human rights groups report.

The issue is, predictably, contentious. Seventy-nine percent of Brazilians told pollsters in 2014 that they were against legalizing abortion.

Experts give varying answers on how soon in a pregnancy it is possible to tell if a fetus is developing an abnormally small head. Preliminary analysis by the CDC suggests mothers in Brazil who gave birth to infants with microcephaly following a Zika illness tended to have been infected with the virus in their first trimesters.

Here in Haiti, where access to health care of all kinds is extremely limited, the disease ranks low on the list of most people’s priorities, especially when compared to soaring food prices, violent protests, and the collapse of the recently attempted presidential elections.

The Pan American Health Organization, which is part of the World Health Organization, has prepared a guide on Zika that instructs women to continue prenatal care, and notes that transmission from mother to fetus has been reported with other mosquito-borne viruses, such as dengue and chikungunya.

But the organization has not made recommendations on pregnancy or birth control in relation to the epidemic so far. “The decision to get pregnant is a decision for each woman,” Dr. Suzanne Jacob Serruya, director of PAHO’s Latin American Center for Perinatology, said by phone from Montevideo, Uruguay.

PAHO is distributing the guides to officials across the region. But communication has been slow in many countries, where many officials are already taking off work in preparation for the Carnival season, when thousands of people from Brazil to Haiti and beyond will gather for raucous street parties — and sex will be on a lot of people’s minds.