Zika and pregnancy: rethinking certain tools

The article by Dr. Jacqueline Pitanguy is clear, relevant, and required. In this brief commentary, I wish to highlight the significance of this type of discussion for the Argentine population and its importance for an adequate understanding of the available tools for an ethical response to the epidemic.

First, Dr. Pitanguy reports on a shared situation: although the Zika virus has not reached the same dimensions in Argentina as it has in Brazil, Argentina is neither exempt nor far removed from the epidemic. Moreover, dengue (transmitted by the same vector, the Aedes aegypti mosquito) reached the city of Buenos Aires this year. We now have a huge number of cases and several deaths from the disease. Consequently, we Argentines cannot be indifferent to these problems currently faced by Brazil.

As discussed by Dr. Pitanguy, the Zika virus affects pregnant women. It particularly impacts the poorest women, mainly those from Northeast Brazil. Dr. Pitanguy discusses the challenges faced by this population, the poverty and lack of respect for their basic rights. Again, Argentina also suffers the same situation of violation of women's sexual and reproductive rights, especially of the poorest women. The North of Argentina is likewise a forgotten territory in which poverty, oblivion, and negligence reign. Our country presents worrisome and significant internal differences in maternal mortality. For example, in 2012 the city of Buenos Aires recorded a maternal mortality rate of 13/100,000, while Formosa (a poor province in the North) showed an exorbitant rate of 123/100,000 and Jujuy (a province bordering on Bolivia), 115/100,000. In such provinces, complications from unsafe abortions are the leading cause of maternal mortality; and abortion is the leading cause of maternal death in 17 of Argentina's 24 provinces ¹1. Luna F. Entre el tabú y el doble estándar: aborto, derechos de las personas LGBT y técnicas de reproducción asistida en Argentina. Revista de Bioética y Derecho 2016; (36):5-22.. Unfortunately we share certain realities with our Brazilian sisters! Injustice and major inequalities are the underlying problem. In both countries, poor women and their suffering are completely ignored.

Second, we should reflect on the current situation. The virus has been associated with the Zika virus congenital syndrome. This means miscarriages, stillbirths, and infants that survive with malformations and neuropathies, which can be mild or extremely severe (there is no uniform set of symptoms). Zika diagnosis is very difficult (there are many asymptomatic cases), but there are also many elements that do not allow identifying it clearly, since it is confused with other diseases. In addition, the diagnosis of microcephaly is generally made in the late stages of pregnancy. The situation certainly raises serious ethical problems. However, we can rely on some elements to solve them. Next, I wish to add other arguments to reinforce the points already addressed by Dr. Pitanguy.

To provide an ethical response, we should begin by acknowledging that there is not one single response to this problem. This means that each woman will know how to assess whether she wants to continue the pregnancy and whether she is willing to bear a child with the risk of this syndrome, or whether she cannot submit to it. Some women, due to religious beliefs, a life project, age, or whatever the reason, will want to continue no matter what happens; but for others, this situation and waiting will produce great anxiety, and they will experience the pregnancy as torture. It also means acknowledging that when dealing with moral agents, we should take account of their values, expectations, fears, and dreams. These women have decision-making capacity - it is incredible to have to argue for women's respect and autonomy in the 21st century! - but given certain behaviors it is important. That these women are poor, uneducated, or illiterate in no way prevents them from making decisions (which is often a veiled form of prejudice) ²2. Luna F. Paternalism and the argument of illiterate people. Bioethics 1995; 9:283-90.^{), (3}3. Luna F. Los analfabetos y el respeto a las personas. In: Platts M, editor. Dilemas éticos. México DF: Fondo de Cultura Económica/Instituto de Investigaciones Filósoficas; 1997. p. 151-61.. Third, it is worthwhile to recall the definition of health by the World Health Organization, which includes mental health. We should thus remember that "the depression that affects 15% to 40% of pregnant women in low and middle income countries is an incapacitating mental disorder with a neurobiological basis and recurrent course, accompanied by other physical and mental conditions, and which can lead to death by suicide" ⁴4. Rondón M. Salud mental y aborto terapéutico. An Fac Med (Perú) 2015; 76:407-11.. Depression, in turn, is closely linked to environmental issues and women's exclusion. Finally, studies have shown that suicide in pregnant women is related to unwanted pregnancy ⁵5. Brockington L. Suicide in women. Int Clin Psychopharmacol 2001; 16 Suppl 2:S7-19.^{), (6}6. Frautschi S, Ceruli A, Maine D. Suicide during pregnancy and its neglect as a component of maternal mortality. Int J Gynaecol Obstet 1994; 47:275-84.. In this sense, the psychological suffering involved in this type of pregnancy can heavily strain the mental health of these women.

What does this mean for public policies? (1) As defended by Dr. Pitanguy, it is the women themselves that should decide whether they want to continue the pregnancy. (2) This does not mean that all the women have to have an abortion, but only those for whom the anxiety, anguish, and fear of bearing a child with the congenital syndrome may seriously affect their mental health. (3) The woman and society should receive exhaustive and impartial information on the risks of Zika virus infection. (4) Therapeutic abortion should be acknowledged, since mental health is at stake and it is absolutely relevant in the case of Zika. (5) Even without expanding the current restrictive interpretation concerning the decriminalization of abortion based on risk to the pregnant woman's life, highlighted by Dr. Pitanguy; the pertinence of the risk to the woman's life should be considered. Mental health in a highly anguishing and unwanted pregnancy may lead to major depression and involve risk to her life. (6) Finally, State and society should accompany the woman's decision, whether through access to safe abortion or by providing adequate services to families of children with microcephaly or other disabilities associated with the Zika virus.

The challenges posed by the Zika virus should certainly make us rethink our legislations, our public policies, and the treatment our societies provide to women.

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