ILLA DEL ROSARIO, Colombia — When Adriana Alvarez was five and a half months pregnant, she developed a rash, fever, and head and body aches, all hallmark symptoms of a Zika infection. Her doctors had told her her baby appeared healthy, but the 18-year-old was still nervous.
She had heard about the fear that contracting Zika while pregnant may cause a baby to be born with an abnormally small head. She had also heard that some women were considering abortions after being told they had Zika.
But even if Alvarez found out her fetus had a malformed head and brain — a condition known as microcephaly — she would not contemplate an abortion, she said. To her, it amounted to killing her baby.
“I couldn’t do it,” said Alvarez, now seven months pregnant, who was waiting for a doctor’s appointment in this northeastern Colombian town.
The Zika outbreak in Latin America and the Caribbean has enflamed a global debate over abortion laws and contraception access in the predominantly Catholic countries where transmission has occurred.
Women’s rights organizations and global health officials have leveraged Zika to shed light on what they say are overly restrictive policies that leave women vulnerable and force families to have severely disabled children they are not equipped to take care of. The pope has even weighed in, maintaining the church’s strong opposition to abortion but suggesting some openness to contraception.
Many religious leaders here in Colombia similarly say the Zika outbreak has not changed their views, and what they tell their parishes, about abortion. “You should never sacrifice the opportunity to have a baby,” said Ruber Carrero López, a Catholic priest in the city of Cúcuta. “Life is a right, and only God takes control over that,” Jesús Hernán Contreras, an evangelical Protestant pastor, told STAT.
But Colombia, in many ways, represents a middle ground in the debate over reproductive rights. Contraception use here is among the most widespread in Latin America. And although abortion is mostly outlawed, a 2006 court decision carved out several “exceptions” for when the procedure is allowed: when the pregnancy results from a rape or incest, when the fetus will not be able to survive after birth, and when the pregnancy threatens the mother’s physical or mental health.
Since then, some observers say they have seen a softening of views on abortion, with more people thinking of the procedure as a private choice. Roughly four in five Colombians are Catholic, and a small majority of Catholics here favor legal abortion in certain cases.
“It’s been only 10 years,” said Dr. Ana Cristina González Vélez, who helped found the women’s rights advocacy group La Mesa. “But I think many things have changed.”
Colombian officials have said that women infected with Zika will be allowed to have abortions, saying it is a health issue and falls under the maternal health exception, and Colombian media have reported women obtaining abortions after being diagnosed with Zika. (Other countries affected by Zika, including Brazil, have more restrictive rules on when abortion is permitted, and some, such as El Salvador, ban abortion entirely.)
“Zika doesn’t need any additional discussion,” said Cristina Villarreal Velásquez, executive director of the Oriéntame Foundation, which provides women’s health care and abortion services in Bogota.
But even if a woman infected with Zika doesn’t have to clear legal hurdles to obtain an abortion, advocates say she may still have trouble getting one.
Some providers may try to deny a woman an abortion, and some women will face family, religious, and societal pressure, they say. Plus, poor or uneducated women — who are more likely to contract Zika because of greater exposure to mosquitoes — may not understand they are allowed to have an abortion, which could drive them to illegal, and unsafe, abortion providers.
“The law is clear, and the law will cover Zika,” said Paula Avila-Guillen, a Colombian-born programs specialist at the Center for Reproductive Rights, a New York-based global advocacy organization. “It’s more about access.”
The specifics of the Zika outbreak in Colombia and what is known about microcephaly both complicate the abortion discussion.
Despite having the largest number of Zika infections outside Brazil — where health officials have documented more than 4,000 confirmed and suspected cases of microcephaly related to the ongoing outbreak — Colombia has not reported any cases of microcephaly that can be tied to Zika.
It might just be a matter of time: The virus was first identified in the country in October, and pregnant women are thought to be most vulnerable during their first, and possibly early second, trimester.
“Women who are already pregnant at this moment are very afraid of the risk of Zika,” said Dr. Juan Carlos Vargas, who directs research for Profamilia, which is often described as Colombia’s Planned Parenthood.
Doctors cannot always detect microcephaly during pregnancy, so a woman with Zika may not know if her fetus is affected. And even if an ultrasound uncovers malformations in the fetus, doctors can’t tell what kind of cognitive or physical deficits a child will have after being born.
“The challenges come in when you see mild abnormalities,” said Dr. Kenneth Mack, a pediatric neurologist at the Mayo Clinic in Minnesota. “Those are children who show a wider degree of variability.”
The concern about Zika has grown so grave that in January Colombian officials asked women to delay pregnancy for six to eight months. Some cities have distributed condoms, but women’s rights organizations have criticized the appeal as unrealistic without a broader campaign to educate Colombians — including men — about contraception.
“It is the women are already facing more marginalization,” said Mónica Roa of Women’s Link Worldwide, who grew up in Colombia.
Fernando Ruiz, the Colombian vice minister of health, acknowledged in an interview with STAT this month that 50 percent of pregnancies were unplanned and would be difficult to prevent. But he pointed to the other 50 percent of pregnancies that are deliberate and said the decision to ask those couples to delay their pregnancies was an effort to be transparent with people.
“We think that it’s better to tell couples there’s a risk that they face,” he said.
Dr. Danelia Cardona, a psychiatrist and director of the pro-life department at the Colombian Catholic Bishops Conference, also criticized the government’s action. The government should spend its resources more aggressively tackling Zika instead of putting pressure on women not to get pregnant, she said.
“Is this really helping the problem?” Cardona said in an interview in her Bogota office. “Or are we creating a panic situation where the people who lose are women?”
Correction: A previous version of a photo caption misspelled the name of Adriana Alvarez.