Abstract

This study sought to understand how the Zika virus epidemic and its consequences on fetal growth influenced the way pregnant women from various socioeconomic status perceive sexual and reproductive rights in a capital city in the northeast of Brazil. The data used in this qualitative research was collected by means of eighteen semi-structured interviews: nine conducted with pregnant women attended at the public health sector and nine at the private health sector. Results show a high occurrence of unintended pregnancy among women attended at the public health sector, which may be justified by barriers in accessing health and information services. Although women adopted prevention measures related to Zika virus infection after pregnancy, their partners did not develop the same behavior - despite the risk of sexual transmission. The Direct Action of Unconstitutionality 5581 fostered the discussion on reproductive rights, presenting, on the one hand, arguments in favor of terminating pregnancy in cases of Zika virus infection by denouncing social injustices and, on the other, mobilizing questions of moral and religious nature, thus dividing opinions on this matter among women.

Keywords:
Zika Virus; Pregnancy; Reproductive Rights; Gender and Health; Family Planning

Introduction

Zika virus (ZIKV) is mainly transmitted by the sting of the Aedes aegypti mosquito. Besides this traditional route of transmission, ZIKV can also be transmitted sexually or transplacentally. It can cause adverse effects on fetal development, such as microcephaly and other congenital changes currently known as congenital zika virus syndrome (CZS). In this scenario, ZIKV-fighting strategies should not be restricted only to vector control measures; instead, they should include actions that broaden the discussions about sexual and reproductive rights, which reinforces the need to investigate the different perceptions and possibilities of access to these rights by women in reproductive age in Brazil (Diniz et al., 2019DINIZ, D. et al. Understanding the sexual and reproductive health needs in Brazil’s Zika-affected region: placing women at the center of the discussion. International Journal of Gynecology & Obstetrics, Hoboken, v. 147, n. 2, p. 268-270, 2019.; Forero-Martínez et al., 2020FORERO-MARTÍNEZ, L. J. et al. Zika and women’s sexual and reproductive health: Critical first steps to understand the role of gender in the Colombian epidemic. International Journal of Gynecology & Obstetrics, Hoboken, v. 148, n. S2, p. 15-19, 2020.).

According to Corrêa and Petchesky (1996CORRÊA, S.; PETCHESKY, R. Direitos sexuais e reprodutivos: uma perspectiva feminista. PHYSIS: Revista Saúde Coletiva, Santana do Parnaíba, v. 6, n. 1-2, p. 147-177, 1996.), sexual and reproductive rights can be understood in terms of power for women to make informed decisions about sexual activity, gynecological health, pregnancy and motherhood, as well as resources for these decisions to be executed safely. However, to fully attain these rights, in addition to female empowerment about control over their own bodies, it is necessary to consider the social environment in which these women are, since female decisions are also influenced by their sexual partners, family members, the community in which they live and society in general.

The consequences of the ZIKV epidemic affect women’s lives disproportionately (Diniz, 2016DINIZ, D. Vírus Zika e mulheres. Cadernos de Saúde Pública, Rio de Janeiro, v. 32, n. 5, p. 1-4, 2016.). This context led Brazilian health authorities to recommend postponing pregnancy. However, these guidelines failed to consider the high rates of unintended pregnancies (Valente, 2017VALENTE, P. K. Zika and reproductive rights in Brazil: challenge to the right to health. AJPH Perspectives, Washington, DC, v. 107, n. 9, p. 1376-1380, 2017.). According to data from the survey “Born in Brazil: National Childbirth Survey”, more than half of the pregnancies in the country are unplanned (Viellas et al., 2014VIELLAS, E. F. et al. Assistência pré-natal no Brasil. Cadernos de Saúde Pública, Rio de Janeiro, v. 30, n. 1, p. S85-S100, 2014.). Such high rates are associated with insufficient reproductive health services, in addition to the poor quality of sex education, high rates of sexual violence and cultural barriers affecting many women, particularly the younger, poor, black and low-educated, which results in inadequate control by these women over their sexual and reproductive lives (Baum et al., 2016BAUM, P. et al. Garantindo uma resposta do setor de saúde com foco nos direitos das mulheres afetadas pelo vírus Zika. Cadernos de Saúde Pública, Rio de Janeiro, v. 32, n. 5, p. 1-4, 2016.; Nunes; Pimenta, 2016NUNES, J.; PIMENTA, D. N. A epidemia de zika e os limites da saúde global. Lua Nova, São Paulo, n. 98, p. 21-46, 2016.; Borges et al., 2018BORGES, A. L. V. et al. Women’s reproductive health knowledge, attitudes and practices in relation to the Zika virus outbreak in northeast Brazil. Plos one, San Francisco, v. 13, n. 3, p. 1- 12, 2018.).

In addition, the ZIKV epidemic also evinces the gender asymmetries in Brazilian society, which naturalize the notion that women are primarily responsible for contraception and, once pregnant, for prevention measures to avoid infection by ZIKV and its fetal outcomes. This conception results in men not being held responsible for pregnancy and care related to virus transmission, which can be seen in the few recommendations for prevention aimed at men, since the virus can be transmitted sexually. Therefore, this situation gave rise to a series of challenges that are related to the autonomy of women concerning the choices relative to their own bodies, effective control over their sex lives, freedom to manage a pregnancy and the right to interrupt gestation (Lesser; Kitron, 2016LESSER, J.; KITRON, U. A geografia social do zika no Brasil. Estudos avançados, São Paulo, v. 30, n. 88, p. 167-175, 2016.; Nunes; Pimenta, 2016NUNES, J.; PIMENTA, D. N. A epidemia de zika e os limites da saúde global. Lua Nova, São Paulo, n. 98, p. 21-46, 2016.; Porto; Moura, 2017PORTO, R.M.; MOURA, P.R.S. O corpo marcado: A construção do discurso midiático sobre zika vírus e microcefalia. Cadernos de gênero e diversidade, Salvador, v. 3, n. 2, p. 158-191, 2017.).

In Brazil, abortion is prohibited by law with rare exceptions, such as cases of sexual violence, when pregnancy endangers the mother’s life or in cases of anencephaly (Brazil, 1940BRASIL. Decreto-Lei nº. 2.848 de 7 de dezembro de 1940. Código Penal. Diário Oficial da União, Rio de Janeiro, 31 dez.1940.; Camargo, 2016CAMARGO, T. M. C. R. O debate sobre aborto e Zika: lições da epidemia de aids. Cadernos de Saúde Pública, Rio de Janeiro, v. 32, n. 5, p. 1-3, 2016.). Yet, it is estimated that approximately one in five Brazilian women have had at least one abortion, and the highest rates are among those with low education and income and those self-declared black, brown and indigenous. Most of these procedures are performed illegally and unsafely, which makes abortion a serious public health problem in the country. Brazil’s ineffectual policies to tackle this issue both fail to reduce occurrences and hinder effective assistance for women in an abortion situation. They also hinder access to methods and information needed to prevent this practice from recurring and imperiling women’s lives (Diniz; Medeiros; Madeiro, 2017DINIZ, D.; MEDEIROS, M.; MADEIRO, A. Pesquisa Nacional de Aborto 2016. Ciência & Saúde Coletiva, Rio de Janeiro, v. 22, n. 2, p. 653-60, 2017.).

The ZIKV epidemic and its association with the CZS has rekindled discussions about the right to abortion in the country (Castilhos; Almeida, 2020CASTILHOS, W.; ALMEIDA, C. Discursos sobre o aborto na epidemia de Zika: análise da cobertura dos jornais O Globo e Folha de S.Paulo. Cadernos de Saúde Pública, Rio de Janeiro, v. 36, supl. 1, 2020.). In August 2016, a Direct Action of Unconstitutionality (ADI 5581) was filed in the Supreme Court (STF) requesting, among other things, that the right to termination of pregnancy be extended to cases of infection by ZIKV during pregnancy (Brazil, 2016BRASIL. Supremo Tribunal Federal. Ação Direta de Inconstitucionalidade 5.581. 2016.). This request is based on women’s right of choice in view of the psychological suffering that a ZIKV infection can cause during pregnancy, in addition to holding the State liable for failure to provide adequate and continuous reproductive health services (Brazil, 2016BRASIL. Supremo Tribunal Federal. Ação Direta de Inconstitucionalidade 5.581. 2016.; Diniz et al., 2017DINIZ, D. et al. Zika virus infection in Brazil and human rights obligations. International Journal of Gynecology & Obstetrics, Hoboken, v. 136, n. 1, p. 105-110, 2017.; Valente, 2017VALENTE, P. K. Zika and reproductive rights in Brazil: challenge to the right to health. AJPH Perspectives, Washington, DC, v. 107, n. 9, p. 1376-1380, 2017.).

The discussions held about the guarantee of sexual and reproductive rights of women in the context of the ZIKV epidemic may encounter difficulty in the current growing political conservatism in the National Congress. However, this discussion cannot be ignored again, since this is an important moment for the State to ensure that women historically unprotected by ineffective public policies have their right to health guaranteed and the right to make decisions with freedom and autonomy to achieve reproductive justice in the country (Camargo, 2016CAMARGO, T. M. C. R. O debate sobre aborto e Zika: lições da epidemia de aids. Cadernos de Saúde Pública, Rio de Janeiro, v. 32, n. 5, p. 1-3, 2016.; Pitanguy, 2016PITANGUY, J. Os direitos reprodutivos das mulheres e a epidemia do Zika vírus. Cadernos de Saúde Pública, Rio de Janeiro, v. 32, n. 5, p. 1-3, 2016.; Valente, 2017VALENTE, P. K. Zika and reproductive rights in Brazil: challenge to the right to health. AJPH Perspectives, Washington, DC, v. 107, n. 9, p. 1376-1380, 2017.).

There has currently been a significant reduction in the number of people infected with ZIKV and CZS in Brazil. However, the Brazilian population remains exposed to the mosquito vector, and this infection may have an endemic seasonal behavior similar to other arboviruses (Netto et al., 2017NETTO, E. M. et al. High Zika vírus seroprevalence in Salvador, Northeastern Brazil limits the potential for further outbreaks. MBio, Baltimore, v. 8, n. 6, p. 1-14, 2017.), which makes it crucial to develop works addressing the gaps in women’s sexual and reproductive rights in order to ensure progress in this debate. Therefore, this research stands out for its original and necessary perspective in seeking to understand how the ZIKV epidemic and its consequences on fetal development have influenced the perception of pregnant women from different socioeconomic backgrounds on sexual and reproductive rights in a capital city in Brazil’s Northeast.

Methodology

A qualitative study was conducted based on semi-structured interviews with pregnant women. Data collection took place between August and October 2018 at a Family Healthcare Facility (USF) and at a private clinic for obstetric care in the city of Salvador, Bahia. This city was chosen because it is located in a region that was one of the epicenters of the ZIKV epidemic in Brazil (Netto et al., 2017NETTO, E. M. et al. High Zika vírus seroprevalence in Salvador, Northeastern Brazil limits the potential for further outbreaks. MBio, Baltimore, v. 8, n. 6, p. 1-14, 2017.). We conducted 18 interviews - nine with pregnant women attended to by the public health sector (Brazilian National Health System - SUS) and nine pregnant women attended to by the private health sector.

The pregnant women were grouped according to their place of residence and which health service they use, as follows: resident in a lower-class neighborhood and user of SUS services; resident in middle-upper class neighborhoods and user of private health services. This selection strategy aimed to ensure wide heterogeneity among the members of this research so as to provide a uniquely rich diversity of experiences and points of view on the reality surrounding them.

The private clinic where this study was conducted was located in an upper-class neighborhood. It had no connections with the SUS and did not accept health insurance coverage, so the only way to access it was by out-of-pocket payment, which selects high-income patients. Conversely, the USF was located in a lower-class neighborhood of the city of Salvador, Bahia. We thus emphasize that these contrasting characteristics aimed to include diverse backgrounds of life experiences in the ZIKV post-epidemic context.

All participants in this study were selected from within the health services. At the private clinic, the pregnant women were invited to participate in the study while they were waiting for their prenatal appointments. The interviews were scheduled for a later time and took place at the clinic or at the women’s workplace or home. At the USF, the pregnant women were also recruited either while waiting for their prenatal appointment or in home visits made by the researcher accompanied by Community Health Agents (ACS). These interviews were conducted at the USF or at the women’s homes.

The field work was carried out by the first author of the study, a nurse and a collective health researcher, which facilitated entry in public and private health services of prenatal care and the discussion of topics unique to the female universe. The second author is an anthropologist and collaborated in guiding the research, data analysis and text review.

The script for the semi-structured interviews addressed the following issues: pregnancy planning after the ZIKV epidemic; behavior changes after the emergence of ZIKV in the country; perceptions of the ZIKV of women in reproductive age; partner engagement in care actions to reduce the risk of ZIKV infection; pregnant women’s perceptions of the ADI 5581 and gender relations. The interviews had an average time of forty minutes. They were recorded in an audio device and subsequently transcribed.

We used the thematic content analysis technique to perform data analysis (Bardin, 2009BARDIN, L. Análise de conteúdo. Lisboa: Edições70, 2009.). For this study, we used the QSR NVivo version 8 qualitative analysis software, which assisted in the coding of the texts for further analysis and interpretation of the material. The data were arranged in a matrix developed from the topics of interest of the study, built out of the interview script, which acted as a guide for the analysis.

The study complied with all the recommendations of Resolution No. 466/2012 of the National Health Council (CNS) and was approved by the Research Ethics Committee of the Institute of Collective Health of Federal university of Bahia (CEP/ISC/UFBA) under Opinion No. 2,770,514. Finally, to protect the confidentiality of the participants, the pregnant women were given fictitious names.

Results and discussion

Characterization of study participants

The pregnant women attended to by the private health sector were named Ester, Francisca, Maria, Jaqueline, Milena, Laura, Alcione, Andrea and Adelaide. Their ages range from 25 to 36 years. Of these women, four declared themselves white, four brown and one could not answer. About their marital status, eight women were married and one was unmarried; for eight of these women, this was the first pregnancy and only one of them already had a child. All women attended to by the private sector had complete higher education and formal employment, with the exception of one, who had incomplete higher education and was away from work at the time of the interview. The religion of these women varied from Catholic to spiritist, while three declared having no religion.

The pregnant women attended to by the public health sector were named Aurora, Nadja, Tania, Teresa, Rita, Júlia, Antônia, Isadora and Angélica. Their ages ranged from 19 to 41 years. Six declared themselves black, two brown and one white. About their marital status, six reported living with their partner, two were married and one was unmarried; this was the first pregnancy for only three of these women. Among the women attended to by the public sector, only two had complete higher education and formal employment, while the others were self-employed or unemployed, and their education varied from incomplete and complete high school. The religion of these women varied from Catholic to evangelical, while two reported just believing in God.

Pregnancy planning after the emergence of ZIKV in Brazil

Studies indicate that birth rates in Brazil declined after the ZIKV epidemic (Castro et al., 2018CASTRO, M. C. et al. Implications of Zika virus and congenital Zika syndrome for the number of live births in Brazil. PNAS, Washington, DC, v. 115, n. 24, p. 6177-6182, 2018.). Our study suggests, however, that pregnancy planning in the post-epidemic context may differ among pregnant women from different socioeconomic strata. Most of the women attended to by the private sector in this study reported that their pregnancies were planned, and some reported that they postponed pregnancy due to the ongoing ZIKV epidemic in the country, as Ester’s testimony shows:

Some pregnant women attended to by the private sector also reported that they did not plan to become pregnant between 2015 and 2016, when the epidemic reached its peak in the country. However, in the current context they have shown the development of strategies for peventing ZIKV infection since the pregnancy planning process, which shows that these women have a high control over their reproductive planning:

Conversely, all the women attended to by the SUS reported that their pregnancies were unplanned and some also reported that the pregnancy was unwanted. Three of these women considered the possibility of termination of pregnancy at the time of the initial diagnosis. Despite this, none reported having effectively sought the procedure. Among the reasons listed for the desire to postpone pregnancy, women reported financial, professional and family instabilities. ZIKV only became a problem after the diagnosis of pregnancy, which generated great anxiety for many of these pregnant women:

Teresa reported failure in the use of contraception, which resulted in an unplanned pregnancy. Some women also mentioned difficult access to their appointed USF to retrieve their contraception or to solve questions about how to use it properly, which shows large gaps in sex education and access to health services that still persist in the country and result in high rates of unintended pregnancies among women from lower socioeconomic strata. These findings are in line with the work developed by Marteleto et al. (2017MARTELETO, L. J. et al. Women’s Reproductive Intentions and Behaviors during the Zika Epidemic in Brazil. Population and Development Review, Hoboken, v. 43, n. 2, p. 199-227, 2017.) on the reproductive intentions of women after the ZIKV epidemic in the country. The author showed that women of higher socioeconomic status may be more successful in preventing an unplanned pregnancy, while among women of lower socioeconomic backgrounds, it is possible to identify high rates of unintended pregnancies (Diniz et al., 2020DINIZ, D. et al. Understanding sexual and reproductive health needs of young women living in Zika affected regions: a qualitative study in northeastern Brazil. Reproductive Health, v. 17, n. 22, p. 1-8, 2020.; Marteleto et al., 2017MARTELETO, L. J. et al. Women’s Reproductive Intentions and Behaviors during the Zika Epidemic in Brazil. Population and Development Review, Hoboken, v. 43, n. 2, p. 199-227, 2017.;).

Precarious socioeconomic conditions associated with the failure of health services to provide adequate information and long-term protection devices are directly related to the high rates of unplanned pregnancies in the country. As a result, to secure reproductive autonomy for all women, it is necessary to ensure the provision of adequate infrastructure and resources, as well as accessible and well-equipped services. Such elements are social rights and are essential for the realization of women’s sexual and reproductive rights. The State is responsible for actions to reduce the existing disparities between groups so as to ensure equality in rights for the entire population (Borges et al., 2018BORGES, A. L. V. et al. Women’s reproductive health knowledge, attitudes and practices in relation to the Zika virus outbreak in northeast Brazil. Plos one, San Francisco, v. 13, n. 3, p. 1- 12, 2018.; Corrêa; Petchesky, 1996CORRÊA, S.; PETCHESKY, R. Direitos sexuais e reprodutivos: uma perspectiva feminista. PHYSIS: Revista Saúde Coletiva, Santana do Parnaíba, v. 6, n. 1-2, p. 147-177, 1996.; Diniz et al., 2020DINIZ, D. et al. Understanding sexual and reproductive health needs of young women living in Zika affected regions: a qualitative study in northeastern Brazil. Reproductive Health, v. 17, n. 22, p. 1-8, 2020.).

Pregnancy in the post-epidemic context has required new daily habits aimed at reducing the risks of infection by ZIKV. Body protection measures, such as using repellents and wearing longer clothing, as well as avoiding visits to places with greater vector circulation, were the most described actions by women. However, the pregnant women in this study also reported constant demands by family members and partners regarding prevention actions, which generated great emotional overload in them. These external demands have also been observed in other studies, which shows that the responsibility to avoid infection by ZIKV during gestation was placed primarily on women (Meireles et al., 2017MEIRELES, J. F. F. et al. Zika vírus and pregnant women: A psychological approach. Psychology & Health, Abingdon, v. 32, n. 7, p. 798-809, 2017.; Porto; Moura, 2017PORTO, R.M.; MOURA, P.R.S. O corpo marcado: A construção do discurso midiático sobre zika vírus e microcefalia. Cadernos de gênero e diversidade, Salvador, v. 3, n. 2, p. 158-191, 2017.).

Though they are important in prevention actions - considering that ZIKV can be transmitted by bodily fluids - pregnant women’s partners were not effectively included in the guidelines created by official institutions for the necessary care to reduce the risk of transplacental infection by ZIKV (Porto; Moura 2017PORTO, R.M.; MOURA, P.R.S. O corpo marcado: A construção do discurso midiático sobre zika vírus e microcefalia. Cadernos de gênero e diversidade, Salvador, v. 3, n. 2, p. 158-191, 2017.; Lesser; Kitron, 2016LESSER, J.; KITRON, U. A geografia social do zika no Brasil. Estudos avançados, São Paulo, v. 30, n. 88, p. 167-175, 2016.; Marteleto et al., 2017MARTELETO, L. J. et al. Women’s Reproductive Intentions and Behaviors during the Zika Epidemic in Brazil. Population and Development Review, Hoboken, v. 43, n. 2, p. 199-227, 2017.). Several women in this study reported resistance on the part of their partners to put into practice prevention actions to avoid mosquito bites. Ester, for example, said that although her partner had a rash during her pregnancy (a characteristic symptom of ZIKV infection), he resisted greatly to using repellent to reduce the risks of exposure to an infection, which shows that the responsibility for the pregnancy and adequate fetal development is directed mainly toward women:

Besides body protection to prevent mosquito bites, the use of condoms is essential to reduce the risks of sexually transmitting the virus to pregnant partners. However, this is not a usual behavior among men, and women reported struggling to negotiate the use of condoms due to a “macho culture” that naturalizes risk behaviors:

Social and cultural hierarchies influence women’s decisions regarding their sexual and reproductive health. Gender asymmetries - expressed by power inequalities between men and women in our society - have a great impact on fertility, sexual activity, pregnancy and motherhood (Corrêa; Petchesky, 1996CORRÊA, S.; PETCHESKY, R. Direitos sexuais e reprodutivos: uma perspectiva feminista. PHYSIS: Revista Saúde Coletiva, Santana do Parnaíba, v. 6, n. 1-2, p. 147-177, 1996.). In this sense, although the ZIKV can be sexually transmitted, men still resist greatly to using birth control barrier methods and transfer the responsibility for prevention to women (Marteleto et al., 2017MARTELETO, L. J. et al. Women’s Reproductive Intentions and Behaviors during the Zika Epidemic in Brazil. Population and Development Review, Hoboken, v. 43, n. 2, p. 199-227, 2017.; Porto; Moura, 2017PORTO, R.M.; MOURA, P.R.S. O corpo marcado: A construção do discurso midiático sobre zika vírus e microcefalia. Cadernos de gênero e diversidade, Salvador, v. 3, n. 2, p. 158-191, 2017.).

Therefore, it is essential that health campaigns include men as subjects equally responsible for the healthy development of the pregnancy by raising awareness of the importance of using birth control barrier methods, considering that men can sexually infect their partners and the guidelines for prevention in the context of the ZIKV epidemic were mostly aimed at women. To achieve this, it is essential to use means of communication that reach men in order to contribute to their awareness and effective change of behavior (Brazil, 2017BRASIL. Ministério da Saúde. Secretaria de Vigilância em Saúde. Secretaria de Atenção à Saúde. Orientações integradas de vigilância e atenção à saúde no âmbito da emergência de saúde pública de importância nacional. Brasília, DF, 2017.; Marteleto et al., 2017MARTELETO, L. J. et al. Women’s Reproductive Intentions and Behaviors during the Zika Epidemic in Brazil. Population and Development Review, Hoboken, v. 43, n. 2, p. 199-227, 2017.).

Pregnant women’s perceptions of reproductive rights in the context of the ZIKV epidemic

The pregnant women in this study were not aware of ADI 5581, filed in the Supreme Court in August 2016. After a brief exposition of the rights requested by this petition, the pregnant women were invited to express their position on the possibility of termination of pregnancy due to ZIKV infection. Despite being previously unaware of ADI 5581, discussions about abortion are part of women’s reproductive life, which allowed the women in this study to express their opinions on the subject based on previous assumptions and beliefs.

These women had different positions regarding the possibility of termination of pregnancy in cases of ZIKV infection, and this position varied regardless of socioeconomic background, education, and which health services they used. To support their positions, the women presented a series of arguments. The majority had a favorable opinion about the discussion proposed by ADI 5581. They supported primarily women’s right of choice over their bodies. According to Maria, a woman connected to the private sector, women should have the right to decide on a pregnancy, considering that men usually abandon their partners when they do not want to take responsibility as fathers, so all the burdens of the pregnancy and of raising the child fall on the woman:

This position is corroborated by Júlia, who is connected to the public sector. She argues that if she were infected by ZIKV during her pregnancy and the action proposed by ADI 5581 were available, she would choose to terminate her pregnancy because she fears being abandoned by her partner and the great financial and emotional overload of raising a child with severe congenital alterations:

Brazil has high rates of children registered without a father. According to the National Council of Justice, there are over five million (Bassette, 2019BASSETTE, F. Brasil tem 5,5 milhões de crianças sem pai no registro. Exame, São Paulo, 31 jan. 2019.), a situation that may have got worse during the ZIKV epidemic as many women were abandoned by their partners after being diagnosed with CZS. The understanding this of situation needs to include the gender issue, considering that men retain the right to choose when to abandon the child and that decision is not a crime, although it may result in serious family repercussions. This context has a great impact on the lives and health of pregnant women, and it is intensified by the inefficient role of the State in ensuring social rights and access to quality health services (Diniz, 2016DINIZ, D. Vírus Zika e mulheres. Cadernos de Saúde Pública, Rio de Janeiro, v. 32, n. 5, p. 1-4, 2016.; Menezes et al., 2019MENEZES, N. M. et al. The discussion on sexual and reproductive rights in the context of zika virus, which way we to tread? Revista Enfermagem Atual In Derme, Rio de Janeiro, n. 87, p. 1- 9, 2019. ; Porto; Moura, 2017PORTO, R.M.; MOURA, P.R.S. O corpo marcado: A construção do discurso midiático sobre zika vírus e microcefalia. Cadernos de gênero e diversidade, Salvador, v. 3, n. 2, p. 158-191, 2017.; Rego; Palácios, 2016REGO, S.; PALÁCIOS, M. Ética, saúde global e a infecção pelo vírus Zika: uma visão a partir do Brasil. Revista bioética, Brasília, DF, v. 24, n. 3, p. 430-34, 2016.).

In this sense, the argument used by the pregnant women to support the right of women to choose termination of pregnancy in cases of infection by ZIKV are is the serious failure of the State to ensure proper assistance for the families affected by CZS. According to Andréa, connected to the private sector, the State does not provide adequate social and health conditions for families of children with CZS, which produces new and serious vulnerabilities in lives jeopardized by social inequalities and health inequities:

The ZIKV epidemic has highlighted the neglect that affects women’s lives. When they are not abandoned by their partners, the State fails to ensure these women basic rights. Most mothers of children with CZS live in places where it is difficult to access health services, where they have to travel long distances to make sure that their children have access to early stimulation medical services. Many leave work because these children require full-time assistance, which directly impacts the income of these families. Although they have the right to Disability Allowance (CPB), obtaining this aid can be extremely bureaucratic, which makes it difficult for families who need it most. Thus, this state of affairs makes these mothers experience the challenge of raising a child with serious limitations and needs, insufficiently covered by the Brazilian State, alone (Diniz, 2016DINIZ, D. Vírus Zika e mulheres. Cadernos de Saúde Pública, Rio de Janeiro, v. 32, n. 5, p. 1-4, 2016.; Porto; Moura, 2017PORTO, R.M.; MOURA, P.R.S. O corpo marcado: A construção do discurso midiático sobre zika vírus e microcefalia. Cadernos de gênero e diversidade, Salvador, v. 3, n. 2, p. 158-191, 2017.).

On the opposite side of the debate, a small part of the pregnant women expressed themselves to be against the proposal of ADI 5581 regarding termination of pregnancy in cases of ZIKV infection, arguing their point of view on ethical, moral, religious grounds and on the discourse of the defense of life. Adelaide, connected to the private sector, argues for her religious beliefs and cites fetal viability in pregnancies of women who were infected with ZIKV during gestation to justify her disagreement with the proposal:

The association between ZIKV and pregnancy requires a reassessment of Brazilian legislation regarding reproductive rights, so that, if an infection occurs during pregnancy, women have autonomy to go through with the pregnancy or not. Such conduct is related to the physical and psychological well-being of these women, as well as the social and cultural backgrounds of these families, factors that may motivate this decision. However, if they wish to go through with the pregnancy, the State must provide full assistance to both mother and child as far as full access to health and social services is concerned (Pitanguy, 2016PITANGUY, J. Os direitos reprodutivos das mulheres e a epidemia do Zika vírus. Cadernos de Saúde Pública, Rio de Janeiro, v. 32, n. 5, p. 1-3, 2016.; Stern, 2016STERN, A. M. Zika and reproductive justice. Cadernos de Saúde Pública, Rio de Janeiro, v. 32, n. 5, p. 1-3, 2016.).

In May 2020, the Supreme Court dismissed ADI 5581, which once again limits the discussion on the expansion of women’s sexual and reproductive rights in the country. Supreme Court Minister Luis Roberto Barroso states in his ruling that this deliberation

Final considerations

This study identified unmet sexual and reproductive health needs. Women from higher socioeconomic strata had high control over their reproductive planning compared to women from lower socioeconomic strata. The latter, though they wanted to postpone pregnancy due to ZIKV-related insecurities struggled to access the information and resources needed to ensure their reproductive autonomy.

Furthermore, health guidelines concentrated the responsibility to prevent infection by ZIKV during pregnancy on women, exempting men from such care. In this sense, it is essential to strengthen strategies including partners in women’s reproductive routine in order to stimulate shared responsibility for proper fetal development, considering that ZIKV can be transmitted sexually.

Finally, the dismissal of ADI 5581 - due to procedural technical issues - limited the debate on the issue of pregnancy termination. Given the current context of political conservatism, it is crucial that this debate keeps its momentum and that more research be developed to propose strategies that guarantee access of all women to sexual and reproductive health services with a view to achieving equitable and comprehensive care. In addition, it is also crucial to investigate the perception of men about actions to prevent ZIKV infection and its consequences.

References

Publication Dates

History