Requests for Abortion in Latin America Related to Concern about Zika Virus Exposure

To the Editor:

On November 17, 2015, the Pan American Health Organization (PAHO) issued an epidemiologic alert regarding Zika virus in Latin America.¹ Several countries subsequently issued health advisories, including cautions about microcephaly, declarations of national emergency, and unprecedented warnings urging women to avoid pregnancy. Yet in most Latin American countries, abortion is illegal or highly restricted,² leaving pregnant women with few options.

For several years, one such option for women in Latin America has been Women on Web (WoW), a nonprofit organization that provides access to abortion medications (mifepristone and misoprostol) outside the formal health care setting through online telemedicine in countries where safe abortion is not universally available.³ We analyzed data with respect to requests for abortion through WoW between January 1, 2010, and March 2, 2016, in 19 Latin American countries. Using a regression-discontinuity design, we assessed whether requests for abortion increased after the PAHO alert, as compared with preannouncement trends.

We classified requests according to self-reported country of origin and divided countries into three groups: group A, with autochthonous Zika transmission, legally restricted abortion, and national public advisories to pregnant women; group B, with no autochthonous Zika transmission and legally restricted abortion; and group C, with autochthonous Zika transmission, legally restricted abortion, and no national advisories. We also included three control countries — Chile, Poland, and Uruguay — in which no increase in requests related to Zika virus infection was expected. (Details are provided in the Supplementary Appendix, available with the full text of this letter at NEJM.org.) During the final 3 study weeks, women were asked specifically if they were seeking abortion because of concern about Zika virus infection. In their response, women did not confirm whether they had received a diagnosis of such infection.

Table 1. Table 1. Number of Online Requests for Abortion Medications after the PAHO Alert Regarding Zika Virus Exposure, According to Country.

In all group A countries except Jamaica, there were statistically significant increases of 36 to 108% over baseline in requests for abortion through WoW after the PAHO announcement (Table 1, and Fig. S3 in the Supplementary Appendix). In group B, small increases were observed in two countries, Argentina and Peru. In the latter, officials sparked concern about Zika virus infection by asking the government to declare a preemptive state of emergency.⁴ No significant increases were observed in group C or in any control countries. We cannot definitively attribute the rapid acceleration in requests in group A to concern about Zika virus exposure. However, the percentage of women in each country who reported such concern as their reason for seeking abortion correlates with the observed country-specific increases in requests over baseline trends (Table S1 in the Supplementary Appendix).

In Latin American countries that issued warnings to pregnant women about complications associated with Zika virus infection, requests for abortion through WoW increased significantly. Our approach may underestimate the effect of the advisories on demand for abortion, since many women may have used an unsafe method, accessed misoprostol from local pharmacies or the black market, or visited local underground providers. But accurate data on these choices are difficult to obtain.⁵ Thus, our data provide a window on how concern about Zika virus infection may have affected the lives of pregnant women in Latin America.

Models that were developed by the World Health Organization predict that 3 million to 4 million persons across the Americas (including North America, Central America, South America, and the Caribbean) will contract Zika virus infection through early 2017, and the virus will inevitably spread to other countries where access to safe abortion is restricted. Official information and advice about potential exposure to the Zika virus should be accompanied by efforts to ensure that all reproductive choices are safe, legal, and accessible.

Abigail R.A. Aiken, M.D., Ph.D.
James G. Scott, Ph.D.
University of Texas at Austin, Austin, TX
[email protected]

Rebecca Gomperts, M.D., Ph.D.
Women on Web, Amsterdam, the Netherlands

James Trussell, Ph.D.
Princeton University, Princeton, NJ

Marc Worrell
Women on Web, Amsterdam, the Netherlands

Catherine E. Aiken, M.D., Ph.D.
University of Cambridge, Cambridge, United Kingdom

This letter was published on June 22, 2016, at NEJM.org.