The presence of the Zika virus in El Salvador, along with the evidence that it may be causing microcephaly in fetuses and babies, led the country’s Ministry of Health to recommend last week that women should avoid becoming pregnant until 2018. But local feminist groups say this guidance doesn’t reflect the needs of Salvadoran women, especially where reproductive health is concerned.
Last May, there was a Zika outbreak in Brazil; in October, a large number of babies there were born with microcephaly, a condition in which “the head is smaller than normal because the brain has not developed properly or has stopped growing.” According to the New York Times, Zika has existed since about 1947 in Africa. It was not particularly linked to microcephaly until last year, however, because most people had mild cases as children, and had immunity when they reached childbearing age. Still, as the Times notes, “Investigators may even find that Zika virus is not the main cause [of microcephaly], although right now circumstantial evidence strongly suggests that it is.”
The Centers for Disease Control and Prevention reports that an understanding of the links between Zika and microcephaly is “evolving,” but that preventive measures, such as avoiding mosquito bites, are appropriate.
Since the virus has only recently arrived in El Salvador, the Ministry of Health does not yet have records of fetuses diagnosed with microcephaly as a possible result of the Zika virus. However, the data reflect that 96 pregnant women have the virus, and the total number of cases continues to rise.
El Salvador Vice Minister of Health Eduardo Espinoza announced on behalf of the Ministry of Health last week that “We are recommending that women of childbearing age take the precaution of planning their pregnancies and try to avoid pregnancy this year and next.”
As reported in Spanish by La Prensa Gráfica, “The official also [reissued] the call that the Ministry made a few months earlier to women who were already pregnant and could be susceptible to acquiring Zika to ‘cover as much of the body as possible, use pants and long-sleeve blouses to limit the possibility that mosquitoes infected with Zika can affect them.’”
Sara García, coordinator of the feminist group Agrupación Ciudadana por la Despenalización del Aborto (Citizen Group for the Decriminalization of Abortion), says that the recommendation seems directed primarily at adult married women or women who have a stable, cooperative male partner. She noted to RH Reality Check in an on-the-ground interview, “Paternal responsibility is not included. Where are the men in this process?”
Furthermore, about 31 percent of females with pregnancies registered with the El Salvador Ministry of Health in 2014 were ages 10 to 19. Many of these pregnancies, García argued, could have been “imposed,” or nonconsensual. “What happens with an imposed pregnancy?” she said. “What happens when contraceptives fail? We can’t just think about the ideal and assume that everyone can plan pregnancies.”
“This recommendation is not grounded in the realities and the context of El Salvador,” García concluded.
The potential inability to plan for pregnancies—or prevent them—is exacerbated by El Salvador’s weak policies around sexual and reproductive health services. Both García and Salvadoran OB-GYN and specialist in women’s health, Dr. Aleida Marroquín, noted to RH Reality Check that comprehensive sexual education that includes contraception is not available in schools.
Such barriers to access are not limited to education, however. Contraception is not legally restricted in the country. Even so, in a study-in-progress carried out by the feminist organization Organización de Mujeres Salvadoreñas por la Paz (Organization of Salvadoran Women for Peace, known as ORMUSA), which shared a preliminary draft with RHRC, early findings based on interviews indicate that although local health centers might prescribe contraceptives, centers can go for months at a time without actually having any in stock. Young women say they routinely encounter humiliating treatment or have their requests to purchase contraception denied at public clinics and private pharmacies.
In addition, the study reports, although the country’s policies direct that there be specialized services and personnel trained to serve adolescents and young adults, in reality those services rarely exist. Gang violence and territoriality also impact clients’ ability to physically access clinics, and the reporting of rapes for fear of retribution.
And if a person does not prevent pregnancy and discovers that her fetus is showing signs of microcephaly—which, as Marroquín noted, is not possible until the second trimester—El Salvador’s absolute ban on abortion means that she has no choice apart from giving birth.
Marroquín explained, “The symptoms [of microcephaly] can run a continuum from extremely severe with an early death to practically non-detectable and a relatively normal life. However, most babies affected need specialized care from birth, and some will need round-the-clock care all their lives.”
She emphasized that El Salvador has “almost no resources to meet such extensive medical and social needs. What happens to a woman who is an agricultural worker or a vender in the market who must work long hours every day to feed her children?”
Although a woman may or may not wish to interrupt the pregnancy if she were to discover that her fetus was microcephalic, the option does not even exist in the country. This, activists say, reflects the broader problem of denying women access to potentially life-saving care.
“In addition to Zika,” García pointed out, “When we talk about a nonviable pregnancy, about risk, Salvadoran women are confronting other situations too. A major example is ectopic pregnancy, where any medical textbook will tell you that the only way to treat it is to interrupt the pregnancy. Otherwise the fallopian tubes can rupture and cause much graver problems, including the possible death of the woman.”
“What happens in this country?” García continued, referencing anecdotes medical providers had relayed to the Agrupación. “The woman arrives at the hospital. The doctor tells her that they cannot interrupt the pregnancy as long as they can detect a heartbeat. ‘You can stay here in the hospital and wait,’ the doctor tells her. But she has other children to care for at home. If she doesn’t work, they don’t eat. So she goes home and runs the serious risk of having her fallopian tube rupture at home, far from medical help. In cases of ectopic pregnancies, there is no question about what is going to happen, but doctors have their hands tied by the law.”
García also mentioned Beatriz, who turned to international courts for help in 2013 when medical personnel refused to let her terminate a pregnancy of an anencephalic fetus. Beatriz was threatened with prison if she took any action to do so; many other women in the country are currently incarcerated on abortion-related charges because of pregnancy complications.
García linked the Zika issues to the long-term work of the Agrupación to decriminalize abortion and recognize the negative health consequences for women of the absolute ban.
“We need to push the conversation beyond the question of Zika, and talk about the consequences of a law that gives women no options for interrupting a pregnancy, especially when the conditions to prevent pregnancies are almost nonexistent,” she said.
“Other countries in the region have laws that permit therapeutic abortions, abortions in case of rape or incest, and abortions in case of severe fetal abnormalities. We used to have that,” García said.
Since making its initial recommendation that women avoid becoming pregnant, the Ministry of Health has backed off a bit from that stance, instead emphasizing its campaign to eradicate the breeding grounds of the Aedes aegypti mosquitoes that carry Zika. The same insects also transmit dengue fever and Chikungunya, related viruses that have been present for much longer in the country. The government has also recommended that female students be allowed to wear pants as part of their school uniforms rather than the required skirts as one more preventive measure.
However, public officials have yet to suggest proposals for workable policies and practices to prevent unwanted pregnancies, and to provide women options that include abortion.
To schedule an interview with Kathy Bougher contact director of communications Rachel Perrone at firstname.lastname@example.org.