“She is just trying to do everything right for her baby,” my colleague in Puerto Rico told me. At that point, it was too late for her sister to try to prevent an unintended pregnancy. She was already a couple of months along and now trying to figure out what she could do to prevent Zika infection. She felt trapped — homebound in an air-conditioned apartment with her partner, too worried about being exposed to mosquitoes to even go to her doctor appointments. She often thought about leaving the country for the mainland United States, which Puerto Rican citizens can do at any time if they have the financial means.
My colleague was asking for my advice — as a friend, but more as a doctor. In June, when I was on the ground in Puerto Rico working with local providers at community health centers to help stop the spread of Zika, a virus that has become a public health emergency, there were 130 cases of Zika-positive pregnancies on the island. Since then, that number has shot up to about 900 and, today, there are probably many more. Unfortunately, I had little to share with her that day other than the typical lines: We don’t know much, she should stay protected if she can with mosquito nets and condoms.
During pregnancy, a woman often worries about the food she’s eating, if she’s sleeping in the right position. The threat of Zika doesn’t just alter the equation: It blows it up. As part of my OB/GYN family-planning fellowship at Boston Medical Center, I helped educate health-care providers of obstetrics and gynecology about patient-centered contraceptive counseling and access to all forms of contraception. The harsh fact, though, is that the virus is spreading much faster than our efforts to spread awareness and resources, and the effects are devastating. Given how quickly people are becoming infected, it is critically important to put contraception into the hands of women in Puerto Rico. It is by no means a cure for those already infected by Zika, but contraception serves to drastically reduce the chances of those infected men and women creating unintended pregnancies that could result in children born with birth defects.
While I was there, I saw for myself how dire the situation is. Women, both pregnant and not pregnant, are terrified. At clinics throughout the island, patients have little or no information about Zika other than to use mosquito spray and nets. Some clinics had some forms of contraception, but the majority barely had oral contraceptive pills in their office to offer patients. Most did not have the newer forms of long-acting reversible contraception (LARC) like the intrauterine devices (IUDs) or an implant. Many providers do not offer abortion services and do not have a place to refer patients that desire counseling on their options. Community health centers, the poorest of clinics there, are doing their best to give people information while barely being able to stock free condoms. Between concerned patients and frustrated physicians, there is so much to be done.
I spent much of my time helping doctors who were new to placing LARC devices. Many doctors told me that they had waiting lists of 40 to 50 patients desperate for any birth control, but particularly for LARC. One patient I saw with a local provider worked in this clinic as a medical technician. She had been waiting for a Mirena (the five-year hormonal IUD), but none of the local providers in that area of the island had it. When she heard the clinic was getting a supply of them, she was first in line to have it placed. For some clinics, when the supply of the new LARC runs out, they may not be able to get more for a very long time.
For that reason, I believe we absolutely cannot make any strides in the fight against Zika without funding for family planning services. Period. We do not yet have an effective means to reduce infection rates or cure women or men currently infected with the virus. The only scientifically proven weapons we have against more babies born with Zika-related birth defects are reproductive health services. The sad fact is that while Congress delays access to much-needed resources because of ideological differences about whether family planning should be funded by a portion of the Zika bill, more and more women and men are becoming infected. Reproductive autonomy — the ability to control when and if a woman becomes pregnant or chooses to continue a pregnancy — is at the heart of all of these delays. But the bottom line is: Providing reproductive health services to those in Zika-affected areas is vital to protecting women’s and children’s health.
This is the worst time for Zika to have hit the island: right in the middle of an economic crisis, with many people migrating to the mainland in search of better jobs. Many women need a new birth-control method for reasons that have nothing to do with Zika — they’re more worried about work or feeding their children than a Zika-infected pregnancy. For some Puerto Ricans, Zika is just another mosquito-borne illness like dengue, one of the many that have hit the country and been overcome before. In their eyes, this is the government making a fuss over nothing. Or worse: the government using an alleged epidemic as an opportunity to push birth control on its people.
As a Puerto Rican, I am very sensitive to the terrible history of birth control here. This stems from the development of the first birth control pill, for which initial experiments were done on Puerto Rican women — some of whom did not know to what they were consenting. Puerto Rican women were also victim to coerced sterilization procedures during most of the 20th century, which has left Puerto Rico with one of the highest rate of sterilized people in the world. About 39 percent of Puerto Rican women use tubal ligation as their form of birth control, only topped by the Dominican Republic’s 47 percent. Despite 85 percent of Puerto Ricans identifying as Catholic, the majority use birth control in some form. Without access to effective alternatives, women typically chose between birth control pills or sterilization. Because most women are only familiar with those two contraceptive methods, many are skeptical about LARC and sing old tunes about infection and infertility risks that with new IUDs have long been disproved.
We must acknowledge this history, but it shouldn’t impede the work that needs to be done now. In Puerto Rico, more than 65 percent of pregnancies are unplanned. While education may be part of the battle, the lack of access to comprehensive contraception services leaves women vulnerable because they are unable to adequately control their fertility. Abortion care is still something that is not talked about without hushed voices, and there are few providers that advertise these services.
Each second we wait means more pregnant women will have affected pregnancies. We know that contraception and abortion access will prevent more children from being born with serious abnormalities — so why aren’t we giving women and their doctors the tools they need? First, information needs to be more available so that women can make informed decision about their reproductive health care. This includes the fact that Zika is transmitted sexually for possibly months after exposure, and condoms can reduce transmission risk. Contraception should become more readily accessible to all women, regardless of income. Also, abortion should not have the roadblocks it currently has, especially when a Zika-affected pregnancy diagnosed in the second trimester means that time is critical. Puerto Rico’s current Zika crisis should be a wake-up call for all Americans, particularly Congress. Our representatives should accept that the need for abortion care will increase as Zika spreads further into the mainland United States. We have a responsibility to all of our citizens to make it easier to access the full spectrum of care and accurate information so that women like my colleague’s sister have everything they need in the fight against this virus.