Keywords
zika virus infection - abortion - bioethics
Palavras-chave
infecção pelo zika vírus - aborto - bioética
Introduction
The World Health Organization (WHO) specifies abortion as the product of pregnancy
weighing ∼ 1.1 that is removed or eliminated from the body of the mother at less than
22 weeks.[1] Therefore, any fetus that dies after this period and/or weighs less than 1.1 pounds
is considered as a stillbirth. In the scenario of international health public emergency
(IHPE) regarding the Zika virus, the discussion about the legalization of abortion
in cases of congenital Zika virus syndrome (CZS) came to light.[2] In this way, we propose to conduct a review of the literature on abortion and its
relationship with the cases of CZS in Brazil.
Methods
We sought articles published in the Pubmed, Scielo, LILACS and Google Scholar databases
from 2012 to June 2017. The electronic sources were researched in July 2017 using
the advanced search in these databases and the keywords abortion, miscarriage, and zika, with interposition of the Boolean operator “AND.” The inclusion criteria were articles
available in full online, regardless of the methodological approach, published in
Portuguese, English or Spanish, with abstracts indexed in the aforementioned databases.
We excluded articles that did not describe cases related to abortion/Zika virus, and
those that were related to miscarriages caused by Zika virus infection.
Results
We identified 54 publications potentially eligible in accordance with the flowchart
shown in [Fig. 1]. We initially analyzed the title and abstract of the articles. After this review,
and considering the exclusion criteria and duplicates, we selected 16 articles to
be read in their entirety. Information pertaining to the selected articles, such as
the author, year of publication, journal name, title, summary/conclusions, and whether
the authors were in favor of abortion in the cases they described, is contained in
[Table 1],[3]
[4]
[5]
[6]
[7]
[8]
[9]
[10]
[11]
[12]
[13]
[14]
[15]
[16]
[17] according to the year in which the articles were published. The 16 selected articles
were published in 2016 (81.3%) and 2017 (18.7%). Of these, 10 (62.5%) were published
in journals that were not Brazilian. Of these journals, one was in the legal field,
and the remainder was in the medical and health sciences fields. Among the authors,
15 (93.8%) were in favor of abortion for cases involving children with CZS.
Table 1
Information about the selected articles
|
Author
|
Year/ month
|
Journal
|
Title
|
Abstract/conclusions
|
Abortion-friendly?
|
|
Rego and Palácios[2]
|
2016/Dec
|
Revista Bioética
|
Ética, saúde global e a infecção pelo vírus Zika: uma visão a partir do Brasil
|
The authors show that Zika virus infection occurs mainly in pregnant women of the
poorest classes, causing both economic and information inequality to suddenly reach
these women. The authors provide these facts to justify the legalization of abortion
in countries where abortion is still a crime for women with Zika virus infection.
|
Yes
|
|
Roa[4]
|
2016/Feb
|
The Lancet
|
Zika virus outbreak: reproductive health and rights in Latin America
|
The author focuses on the lack of information regarding the severity of the consequences
of the Zika virus infection, as well as the difficulty of access to the methods of
contraception and reproductive health. The author exemplifies this fact by stating
that the most disadvantaged women are likely to earn low wages. The article concludes
by stating that the Zika epidemic may be an opportunity for governments to discuss
safe abortion.
|
Yes
|
|
Camargo[5]
|
2016/May
|
Cadernos de Saúde Pública
|
O debate sobre aborto e Zika: lições da epidemia de Aids
|
The author refers to the legality of abortion, bringing up proposals similar to those
of the AIDS epidemic in 1990. The author also refers to the increase in the number
of evangelical congressmen who seek to increasingly restrict the right to abortion.
The article concludes with the notion that pregnant women with fetuses with microcephaly
are forced to carry on with the pregnancy and give birth, and are often abandoned
by their husbands, being left with the burden of having to care for a disabled infant
alone.
|
Yes
|
|
Pitanguy[6]
|
2016/May
|
Cadernos de Saúde Pública
|
Os direitos reprodutivos das mulheres e a epidemia do Zika vírus
|
The article discusses that the fear of microcephaly constitutes emotional torture
for the mother, which brings up the issue of women's reproductive rights, which would
require a revision in Brazilian legislation. It talks about the high rates of morbidity
and mortality in unsafe abortions. It concludes by reinforcing the importance that
the State provide assistance to mothers who decide to have their children with CZS,
as well as assistance to the children.
|
Yes
|
|
Mayor[7]
|
2016/Jun
|
British Medical Journal
|
Abortion requests increase in Latin America after Zika warning, figures show
|
The author relates to the Pan American Health Organization's alert about the Zika
virus and the increase in the number of abortion drug requests sent to the non-governmental
organization Women on Web. The article shows that requests from Brazil have doubled.
It concludes that the reproductive choice must be safe, legal and accessible.
|
Yes
|
|
Galli[8]
|
2016/Jun
|
Cadernos de Saúde Pública
|
Aonde está o direito ao aborto? Comentário sobre o documentário Zika, The Film
|
This is a commentary on the documentary addressing the restriction to the right of
women to end a gestation. It concludes that there are difficulties both in relation
to the prenatal diagnosis and the information that is passed on to mothers about the
complexity of congenital Zika virus syndrome.
|
Yes
|
|
Aiken et al[9]
|
2016/Jul
|
New England Journal of Medicine
|
Requests for abortion in Latin America related to concern about Zika virus exposure
|
The article refers to Women on Web, a non-governmental organization that provides
abortive medicines. The authors survey the requests for these drugs, before and after
the Zika infection outbreak, and compare countries that have legalized abortion and
those that have not. They conclude that there was an increase in the number of requests
for these drugs, mainly in Brazil, but it is not possible to ensure that this increase
is related to the infection by the Zika virus.
|
Yes
|
|
Collucci[10]
|
2016/Aug
|
British Medical Journal
|
Brazilian attorneys demand abortion rights for women infected with Zika
|
The article discusses the passivity of women in taking control of their lives, in
view of the illegality of abortion, as well as the importance of offering social and
health support to mothers who wish to continue the gestation of fetuses with microcephaly.
It concludes that women who contracted the Zika virus during pregnancy and are in
great mental suffering, which has been diagnosed after medical and psychological evaluations,
should be entitled to an abortion.
|
Yes
|
|
Ventura and Camargo[11]
|
2016/Aug
|
Direito e Práxis
|
Direito reprodutivo e aborto: as mulheres na epidemia de Zika
|
The authors discuss the matter from a legal perspective. They note the lack of access
to public health services and methods of contraception for the poorest women. They
conclude that, based on the reproductive rights and private autonomy in the reproductive
and sexual scope proposed in the Brazilian Federal Constitution, abortion in these
cases should be allowed.
|
Yes
|
|
Campos[12]
|
2016/Nov
|
Medicine, Health Care and Philosophy
|
Zika, public health, and the distraction of abortion
|
The author raises the idea that the discussion of abortion in the cases of congenital
Zika syndrome can be a distraction when more important issues, such as preventative
actions, are not being given due attention. In addition, the article refers to Zika
as a neglected disease because it is related to poverty; thus, few resources are available
to subsidize research for a treatment and for vaccines. It concludes that it is imperative
that there be a discussion about prevention methods before discussing abortion.
|
No
|
|
Perry and Beca[13]
|
2017/Feb
|
Revista Chilena de Obstetricia y Ginecología
|
Virus Zika y aborto por correspondencia: una realidad cercana a Chile
|
The article shows various information about what is occurring in countries where abortion
is restricted and Zika virus infection is spreading. Based on the facts, the authors
try to expose women's risks of using clandestine abortions or non-governmental organizations
such as Women on Web, which provides abortion drugs. The article attempts to show
that in addition to the risk to the lives of women who undergo these procedures, they
become criminals, making that not only a social problem, but also a legal problem.
|
Yes
|
|
Blanchard and Starrs[3]
|
2017/Apr
|
The Lancet
|
Contraception, safe abortion, and the Zika response
|
The article shows that it is important for the government to invest in preventing
unwanted pregnancies during times of congenital infection by the Zika virus. The authors
state that it is necessary to raise women's awareness so that they do not have unwanted
pregnancies, and for the government to offer the appropriate preventive methods so
that they can choose the best method for them. In addition, the authors state that,
if women wish to terminate a pregnancy, they should have this right and should be
directed to do so as safely as possible.
|
Yes
|
|
Ali et al[14]
|
2017/Feb
|
Reproductive Health
|
Study protocol on establishment of sentinel sites network for contraceptive and abortion
trends, needs and utilization of services in Zika virus-affected countries
|
The article describes the implementation of a counseling program for women who are
pregnant or plan to become pregnant, and who are infected or at risk of infection
by the Zika virus. The authors show the need for family planning, contraception and
safe abortion. The goal of the program is to deploy a sentinel network of sites to
transmit safe information to women in countries at the highest risk of congenital
infection by the Zika virus, and it would be a pilot program in sex education for
the future needs generated by other emerging infections.
|
Yes
|
|
Galli and Deslandes[15]
|
2016/Apr
|
Cadernos de Saúde Pública
|
Ameaças de retrocesso nas políticas de saúde sexual e reprodutiva no Brasil em tempos
de epidemia de Zika
|
The article mentions that Brazil is one of the most restrictive countries in the world
regarding abortion laws. The authors cite Brazilian laws, which, on the one hand,
consider the reproductive and sexual rights of women and, on the other hand, are harsh
and restrictive regarding abortion. In addition, the article associates restrictive
laws with the Christian churches' influence on Brazilian laws. It ends by suggesting
that health policies should be reviewed to provide abortion and safe information for
pregnant women with congenital infection by the Zika virus.
|
Yes
|
|
Vélez and Diniz[16]
|
2016/Nov
|
Reproductive Health Matters
|
Inequality, Zika epidemics, and the lack of reproductive rights in Latin America
|
The article shows that social inequality leads to a greater number of cases of Zika
in pregnant women from poor neighborhoods, which present more favorable conditions
for the appearance of the mosquito that transmits the disease, such as lack of sanitation
and health education. In view of this, these women suffer more with congenital Zika
virus syndrome because they must spend more time caring for their children, often
leaving them to go to work. Thus, the authors argue that having a child with neurological
diseases only increases the burden they already carry due to poverty and vulnerability.
|
Yes
|
|
Burke and Moreau[17]
|
2016/Sep
|
Seminars In Reproductive Medicine
|
Family Planning and Zika Virus: The Power of Prevention
|
The article seeks to show that family planning programs can be a powerful tool to
reduce the impact of congenital Zika virus syndrome, especially in Latin American
countries. The authors focus on restrictive abortion laws in some Latin American countries,
which are among the main foci of Zika virus infection, and show an increase in the
number of abortion drug requests in those countries. Thus, the authors argue that,
in addition to prevention and planning, there must be safe abortion facilities for
cases of congenital Zika virus syndrome.
|
Yes
|
Fig. 1 Flowchart of the selection of the articles.
Discussion
Considering the articles, we noticed that most authors were in favor of abortion in
the cases of CZS. However, one must be aware of the problems indicated by these articles.
Most articles note that women do not have access to preventative methods and information.
In view of this, the main point that should be addressed by the governments involved
would be health education associated with the greater availability of quality contraceptive
methods. On the other hand, the articles also address the issue of unsafe abortion,
which often occurs in countries where abortion is prohibited, placing women's lives
at great risk. Much of the literature favors legalizing abortion in cases of CZS,
but it is important that advances be made in the availability of quality diagnostic
methods so that miscarriages are not misleading.
Much of the selected literature refers to the lack of information about the risks
and severity of CZS. In fact, there is a need to discuss various points of view, and,
from there, allow women access to safe and legal abortion. An abortion provided in
Brazil can be considered unsafe because of the ignorance of the professionals[18] and the fact that abortion is a crime according to Brazilian law, and it is among
the main causes of maternal mortality in the country. Therefore, it is considered
a public health problem, indicating that we must consider its dimension.[19]
[20] In addition, the discussion should be a way to educate, from personal impressions,
life experiences, beliefs and cultures of the people involved, regardless of the socioeconomic
level, to the technical knowledge of the related professionals in the context. In
Brazil, induced abortion is related to unfavorable socioeconomic conditions.[21]
[22] From the bilateral elucidation of the suggestion of abortion, as well as its risks
and indications, patients may be able to make an informed decision.[23]
The topic of abortion involves several areas, including the legal, economic, social
and psychological fields. Moreover, the impact on women's life, health and autonomy
is perceptible, and it is still possible to perceive the difference in these variables
in countries where the procedure is legal. In Asia and in countries such as the United
States, where abortion is permitted, access to the procedure is not widespread because
of a lack of sufficient federal resources and difficulty in the access to health services.[24] In addition, the political influence of the Christian churches on the laws criminalizing
abortion is still very strong, especially in Latin American countries.[25]
In Brazil, the first Criminal Code of the Empire, from 1830, criminalized the act
of abortion and, in 1890, the Penal Code also criminalized self-induced abortion.
The constitutional amendment 2848/1940 made abortion legal in situations of risk to
the life of the pregnant woman and of rape.[26] Only in 2012 a new amendment was approved, which allowed abortion also in cases
of unequivocal diagnosis of anencephaly.[27] However, unsafe abortion in Brazil has a strong association with high rates of maternal
mortality.[28]
In Brazil, there is evidence that the access to safe abortion methods by women with
lower purchasing power is different from the access of women with more financial resources.
However, this situation may not change with the legalization of abortion, which occurred
in the United States and Asia.[25] This situation happens mainly because many women wait too long for specialized consultations,
and there is a lack of hospital beds and of access to complementary tests to diagnose
genetic diseases during prenatal care. In addition, considering that in Brazil abortion
does not constitute an obstetric emergency, these pregnant women may again be queued
for an elective procedure with a great risk that when their turn arrives, their babies
have already been born.
There is no prerogative for abortion in the cases of confirmed maternal infection
by Zika virus. Until now, commercially available tests for specific laboratory diagnosis,
such as the reverse transcription polymerase chain reaction (RT-PCR), detect viral
particles and suggest that the mother had contact with viruses, but they do not guarantee
that the fetus has been infected or that it will have microcephaly or any of the other
limitations associated with CZS. Most prenatal diagnoses of microcephaly or brain
injury in cases of CZS are made in the third trimester of pregnancy, when it is no
longer possible to discuss abortion but of preterm or infanticide.[29]
[30]
The possibility of amniocentesis for the diagnosis of CZS has been raised. However,
studies have shown that the examination should be performed only after the 15th week,
due to the risks to the fetus, which is in line with the late diagnosis of the other
methods. Positivity in the fluid may suggest that the fetus is infected, that is,
it does not allow diagnostic certainty. In addition, the negativity in the amniotic
fluid is not completely reliable in showing that the fetus is not infected.[31] Therefore, amniocentesis is a procedure that poses numerous risks, and is not effective
in order to make a definitive diagnosis, which is necessary for an abortion.
The legalization of abortion in the first trimester of pregnancy in cases of confirmed
maternal infection by Zika virus may pave the way for potentially healthy fetuses
to be aborted. Abortion in fetuses with congenital malformations of infectious cause,
mainly toxoplasmosis, rubella and cytomegalovirus, has already been discussed among
specialists over the years. This discussion was made possible by the development of
tests, such as the RT-PCR, that can diagnose these diseases early.[32] However, concerning the Zika virus, we must consider that, although studies have
shown that the placenta is more sensitive to Zika virus attack in the first trimester
of pregnancy and does not have the immunological defenses fully constituted to block
the entry of the virus, there is also scientific evidence of cases in which the pregnant
woman had laboratory-confirmed infection by Zika virus, and the fetus was not affected.[29]
[33]
[34] Thus, abortions may be performed motivated only by the fear of having a disabled
child.
Other unanswered questions arise concerning this topic, such as why the discussion
of abortion in Brazil is only associated with Zika virus infection. After all, the
country is affected by other genetic and congenital diseases that are incompatible
with life, and that may even be diagnosed in the uterus, but pregnant women are prohibited
by law to have abortions, except in cases of anencephaly.[27] Is the situation of the country's lack of health structure for the treatment of
rare diseases or congenital malformations not the same as that of the children affected
by CZS? Why do the other more common causes of disability, such as the sequelae of
prematurity or neonatal hypoxia, which do not have access to early stimulation, not
garner the same concern? Does those who discuss the abortion of children with CZS-associated
microcephaly hear the opinion of the mothers of those affected?
Recent articles have indicated a prevalence of CZS of ∼ 10% of the fetuses of women
who had Zika virus infection confirmed in the laboratory during gestation, and the
legalization of abortion in these cases could directly implicate the death of potentially
healthy fetuses or of those without microcephaly.[32]
Conclusion
We must consider that there is still great social inequality in Brazil, and if there
was an effective program of mosquito prevention, in addition to access to quality
contraceptive methods and access to proper sex education programs, women would be
better able to understand the situation and to make more informed decisions concerning
their right to have an abortion. In addition, it is necessary to develop tests that
can diagnose in the first trimester of pregnancy if the fetus was affected by the
Zika virus to subsidize a qualified discussion about abortion in cases of CZS. As
long as there are no earlier and more accessible forms of diagnosis of CZS, we will
risk suggesting the abortion of potentially healthy fetuses or even performing infanticide
rather than abortion.
