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Zika, abortion and health emergencies: a review of contemporary debates
Globalization and Health volume 15, Article number: 49 (2019)
The Zika outbreak provides pertinent case study for considering the impact of health emergencies on abortion decision-making and/or for positioning abortion in global health security debates.
This paper provides a baseline of contemporary debates taking place in the intersection of two key health policy areas, and seeks to understand how health emergency preparedness frameworks and the broader global health security infrastructure is prepared to respond to future crises which implicate sexual and reproductive rights. Our paper suggests there are three key themes that emerge from the literature; 1) the lack of consideration of sexual and reproductive health (SRH) services in outbreak response 2) structural inequalities permeate the landscape of health emergencies, epitomised by Zika, and 3) the need for rights based approaches to health.
Global health security planning and response should specifically include programmatic activity for SRH provision during health emergencies.
Introduction and background
We set out to understand the intersection of health emergencies and abortion, using the case study of the Zika outbreak (2015–7). We chose to examine this intersection in Brazil, Colombia and El Salvador, each of these countries had Zika infection (albeit with different incidence), yet represent different regulatory environments for abortion, ranging from legalisation in Colombia  to criminalisation in El Salvador  and Brazil, which even lists abortifacient medication on its prohibited drugs list . During the Zika outbreak requests for online abortion pills from women in Brazil doubled between November 2015 and March 2016, and increased by more than a third in El Salvador (35%)  and in Colombia (38.7%) . Whilst these findings cannot be conclusively attributed to the Zika outbreak, it led us to question how health emergencies and abortion inter-relate in practice, and what implications this might have for health emergency preparedness for the future.
We suggest that the Zika outbreak provides the empirical setting for considering the impact of health emergencies on abortion decision-making and/or for positioning abortion in global health security debates. In doing so, we establish a baseline of contemporary research raised by this intersection of health policy areas, and seek to understand how health emergency preparedness frameworks and the broader global health security infrastructure is prepared to respond to future crises which implicate sexual and reproductive rights. Our commentary suggests there are three key themes that emerge from the literature; 1) the lack of consideration of sexual and reproductive health (SRH) services in outbreak response 2) structural inequalities permeate the landscape of health emergencies, and 3) the need for rights based approaches to health.
Before presenting these three key findings, we will first define our three areas of investigation.
Health emergencies fit within a broader framework of global health security [6, 7] and refer to acute public health events which the World Health Organization (WHO) defines as “an extraordinary event which … constitute [s] a public health risk to other states through the international spread of disease and/or to potentially require a coordinated response” . This has been embodied in legislation through the WHO’s Public Health Emergency of International Concern (PHEIC) and mirrored in national legislation such as Brazil’s “Emergência em Saúde Pública de Importância Nacional” (Public Health Emergency of National Importance) (ESPIN). Such policies are important to analyse as the designation of an emergency response allows response activities which go beyond routine health control measures, often focused on short-term outcomes to end an outbreak event. These can include extraordinary financing, restrictive quarantine measures or calling on non-routine health providers, such as the military, to provide assistance. Importantly, such policies promote a firefighting approach to disease control rather than systemic changes that may provide more sustainable long-term capacity to manage or minimise future outbreaks and build more resilient health systems.
Zika is an aborviral disease spread by the Aedes aegypti mosquito. For most people the infection only displays minor flu-like symptoms and has no lasting consequences. However, during 2015–6, assertions were made by clinicians and researchers in Brazil concerned by a cohort of women who were infected with Zika (or Zika-like symptoms) during their pregnancy and went on to have babies born with microcephaly (a neonatal malformation where a baby’s head is smaller than expected) and other developmental complications collectively called Congenital Zika Syndrome (CZS). In Brazil, this led to an “emergencised” response, including the designation of an ESPIN and the deployment of the military to combat the mosquito.
On 1st February 2016, the WHO declared Zika related microcephaly to be a PHEIC. Notably, this PHEIC was declared “not on the basis of what is currently known about the Zika virus …. rather on the basis of what is not known about the clusters of microcephaly” . Further research has proved a causal relationship between Zika virus infection during pregnancy and CZS [10, 11]. It is estimated that between 5 and 15% of babies whose mothers are known to have had a Zika infection whilst pregnant are infected with CZS [12,13,14,15].
The key traits of the securitized response to this outbreak were 1) destruction and fumigation of mosquitos and their breeding grounds, 2) a medicalized focus on development of vaccines, diagnostics and genetically modified mosquitos , 3) advising women of reproductive age that they should not get pregnant . Whilst this policy response (alongside the epidemic characteristics of the disease reducing the susceptible population) resulted in a sharp decline in new cases of Zika (and CZS), what was notably absent from the response was access to abortion options.
Abortion is a common feature of people’s reproductive lives. While procedures for inducing safe abortion are straightforward – including medical abortion, the use of a drug or combination of drugs for pregnancy termination - whether or not abortion is available or un/safe is influenced by a complex mix of politics, access, social attitudes and individual experiences . Importantly, two countries in Latin America that had high incidences of Zika during the 2015–7 outbreak have some of the most restrictive abortion regulations globally:
Abortion is illegal in Brazil, except when a pregnancy may threaten a woman’s life or if it is the result of a case of rape or incest (article 128, I and II) . In 2012, the Brazilian Supreme Court voted in favour of allowing abortion in the case of anencephaly (where a foetus is developing without a brain) . In El Salvador, abortion is illegal and criminalized, according to Chapter II of the Salvadorian Penal Code . As a consequence, dozens of El Salvadorean women are currently serving prison sentences of up to 40 years on abortion charges, even if it is unclear if they suffered a spontaneous (miscarriage) or induced abortion .
Despite current regulatory restrictions in Brazil, the National Survey on Abortion (PNA) observed that clandestine abortion is a common practice among women . By the age of 40, one in five Brazilian women have had an abortion via different methods dependent on socio-economic status, including homeopathic treatment and medical abortion for lower socio-economic groups and private medical and surgical solutions for higher wealth groups . Rates are higher in the North/Northeast region, higher among poorer populations, and higher among women of colour .
Conversely, Colombia has some of the most progressive abortion laws regionally, with abortion permitted when the pregnancy threatens the woman’s health (broadly defined to include mental and physical concerns); when the pregnancy is a result of rape, incest or artificial insemination without consent; when fetal malformations incompatible with life are diagnosed. Interestingly the legislation does not specify a gestational deadline for abortion, and later term abortions can be sought where they may cause severe anguish or mental disorders .
An estimated 56 million induced abortions occur globally each year  of which 54.9% are unsafeFootnote 1 . This results in a major public health problem, especially in contexts where access to legal abortion is highly restricted. An estimated 7.9% of maternal deaths are due to unsafe abortion . In the aforementioned Zika affected countries this is evident, with approximately 250,000 emergency room visits resulting from complications from unsafe abortions annually . Even in Colombia where regulations permit abortion, there are significant barriers for women’s access  and a significant number of unsafe abortions continue .
Zika, abortion and health emergencies
The Zika outbreak brings to the fore the need to integrate comprehensive SRH, including safe abortion, as an important component of the response to the health emergency, yet this has not occurred. The growing importance of SRH in crisis settings has been recognised, including the importance of access to contraception and maternal care . Work by McGinn and Casey  has put the discussion of abortion in humanitarian settings on the agenda, but none of this work has considered health emergency as a crisis zone for such analysis. Understanding the complexity around obtaining abortion-related care in the context of Zika is urgently needed, especially in light of the intense attention abortion receives, owing to shifting national and international laws, policies, treaties, protocols and funding provision . This commentary represents the first step of a larger project exploring this unmet need for abortion during health emergencies, through desk-based research and convening a workshop with leading academics and activists working across the domains of Zika, health emergencies and abortion. In doing so, we have identified three areas where we can see the intersection between these pivotal health policy issues:
SRH only partially woven into the Zika response
A key trait witnessed in the policy response by multiple governments to Zika was to recommend that women avoid or delay pregnancy [34,35,36,37]. Encouraging contraception was one mechanism by which governments promoted such a policy, although it was unclear how women might access these contraceptives in all settings . In Brazil and Colombia it was further advised that pregnant women should not travel to endemic areas, and that those living in these areas should take precautions to avoid mosquito bites [34, 39]. To some extent, this advice was heeded; 56% of Brazilian women said they had either avoided or tried to prevent a pregnancy because of the health emergency , yet this decision was affected by education status, age, religion, socio-economic status, and access to healthcare services . Moreover, a decline of live births subsequent to the Zika outbreak, suggests that women must have taken some steps to avoid or terminate pregnancy [24, 42]. Importantly, however, restrictions on abortion rule out strategies based on screening for CZS infection, which offer the potential to limit the consequences of the virus, but not fertility.
Despite these statistics, one of the most concerning aspects of these governments’ Zika response protocols was the absence of reference to abortion . Only Colombia’s Zika policy listed information about legal abortion practices [44, 45]. However, this advice may not have been widely publicised, with Zika infected Colombians stating that they were never provided with any information about termination of pregnancy as part of their care . This comprehensive information about access to contraception and education around legal reproductive choices must be provided during health emergencies. Zika has shown that a health emergency can have externalities that affect women’s reproductive lives and informed options must be available to them, even in abortion restricted settings.
Responsibility and Structural Inequalities
Policies that advise women avoid pregnancy, use contraception, wear long sleeves, or use insecticide imply that it is the individual woman’s choice, and therefore responsibility to self-manage her risk profile during the outbreak. Mirroring criticisms of policies which placed women in a position of responsibility for HIV/AIDS prevention , taking heed of government positions for Zika might imply that if a woman does have a baby with CZS then it is the woman’s responsibility for not following official advice . Such policies fail to take into account the structural inequalities that pervades everyday life in Latin America. Nunes and Pimenta have established structural factors which put traditionally neglected communities at higher risk of being bitten by a mosquito . This includes poor, black or indigenous women, living in remote locations, with low levels of education dominated by the rampant inequalities that pervade Latin American society [50, 51]. Velez and Diniz consider Zika to be a hidden pandemic  as it is women, without political capital, who have ultimately born the burden of raising children with CZS and the least financially equipped to access medical and social support that a child with a disability needs .
Moreover, by placing responsibility onto women, it suggests that men do not have the same responsibility for pregnancy and further implications of CZS, and creates an unequal gender dynamic to the outbreak . Davies and Bennett highlight the gaps rendered by those in the public health community responding to an outbreak of infectious disease which ignore the structural gender inequalities which pervade most health systems. They refer to this in relation to Watson and Mason’s “tyranny of the urgent” which relegates structural concerns to low priority in order to exercise the autonomy presumed by the international advice (in this case, the declaration of the PHEIC) .
Further, Moeller argues that by framing Zika infection control as a woman’s responsibility, governments may be able to downplay their own inadequacies and failures in limiting the spread of the mosquito through improved water and sanitation facilities or the provision of sexual and reproductive health services . In the northeast of Brazil, where the epicentre of CZS cases occurred, only 51% of households had access to basic sanitation in 2012 . This means that households are required to collect and store water in houses, providing a fertile reservoir for vector development that is inside homes and close to humans [56,57,58]. Souza et al. showe that people with precarious living conditions had a higher prevalence of CZS compared with those who live in better living conditions .
We know from the Ebola outbreak that the crisis exposed weaknesses across health systems [60, 61]. Similarly, the Zika outbreak demonstrated the strength in the health system, particularly in Brazil for rapid vector control activity and sophisticated biomedical research on the virus, transmission patterns and pathogenic effects on foetuses and babies. In contrast, it revealed a systematic gap in women’s health promotion and provision. Previous research demonstrates that Zika hit an already overstretched reproductive health system [62,63,64,65], with high rates of unintended pregnancies in the region, and questions of access to (affordable) contraceptives or clandestine abortions .
These structural factors are not dissimilar to other infectious disease outbreaks, which tend to occur because of environmental factors including deforestation, precarious urbanisation, overcrowded sub-sufficient housing etc. . It is well established that pandemics disproportionately affect the most disadvantaged, meaning that neutral approaches to global Zika planning and response, such as resource allocation will perpetuate and increase existing gender, racial, social and health disparities [53, 67]. As such, responses to health emergencies must actively engage with mechanisms to overcome these barriers, to find a meaningful way to ensure that those most affected or at risk of an outbreak have access to health care and suitable resources when needed.
Rights based approaches to health emergencies
Zika underscores the importance of engaging a rights based frame to situate abortion and reproductive health services during health emergencies. Such championing of a rights based approach is not new in public health emergencies  , and the vulnerability of certain groups has been recognised in the WHO Emergency Response Framework . However, it is even more apparent in the Zika outbreak when considering intersecting issues of SRH, gender, access to health services, as well as in locations with entrenched histories based on rights based approaches to health. Several critiques of Zika policy responses have focused in on issues of women’s ownership and self-determination of their bodies, based on CEDAW’s General Recommendation (No. 24) [40, 70,71,72]. The WHO echoed this rights based approach encouraging policies that allow women and girls to make their own decisions about pregnancy and childbirth , although constrained by the sovereign legislation in member states.
For example, in El Salvador, it has been argued that national laws penalizing abortion during the Zika outbreak (and beyond) do not comply with human rights or international law . Activists have demanded the Salvadorian government take a more rights based approach to the Zika outbreak through legislative reforms to decriminalize abortion . In 2017 (during the Zika outbreak), the UN High Commissioner for Human Rights asked for a moratorium on the criminalisation of women for having an abortion in El Salvador, suggesting that this contradicts international human rights obligations . However, the implementation of a rights based approach faces many barriers. One of them is technocratic resistance to incorporate a consistent rights frame in response to health emergencies. A second, and often more stringent, are anti-abortion views and their ideological effect in health emergencies. In the case of Brazil, for example, groups contesting abortion rights have argued that prioritising womens' right to pregnancy termination in the Zika outbreak violates the rights of disabled babies. There are also those who raised concerns that by focusing too much on the contentious issue of reproductive rights, this can distract from bigger structural factors with wider reaching benefits .
Considering these intersecting themes of Zika, health emergencies and abortion we have centred on three key issues – the role of SRH in health emergencies, structural inequalities and rights based approaches to health . Cutting across these themes is the need for an explicitly gendered or feminist approach to better understanding the connections between Zika, health emergencies and abortion.
However, beyond the literature, we recognise that the Zika crisis and the crisis women find themselves in when seeking an abortion in restrictive settings are not independent of each other. The precarious position women faced during the Zika outbreak, without routine access to SRH services or reproductive rights, whether due to regulation or structural factors, can focus discussions around the depenalisation and liberalisation of abortion laws.
In 2016, the Brazilian National Association of Public Defenders (with support from NGO Anis-Institute of Bioethics) petitioned the Brazilian Supreme Court to allow abortion in the case of women infected by Zika (ADI 5581) . This was followed by the Partido Socialismo e Liberdade (PSOL) (ADPF 442) calling for a full decriminalisation of abortion up to 12 weeks, and a public hearing in the Supreme Court seeking multi-sectoral opinions on matter was held in August, 2018 . The central argument to the first claim is the state’s failure to control the vector, and a woman’s dignity and health, considering her social and economic vulnerability . The ADPF 442 is still pending in the Supreme Court at the time of writing, yet the fact that this occurred shows the catalytic effect that health emergencies can have on regulatory development.
We suggest that behavioural recommendations, such as avoiding pregnancy reinforce unequal power relationships between women and the government with regards to reproductive health options, and instead that health emergency preparedness activity including national response plans, and the International Health Regulations (IHR 2005) should move beyond these behavioural considerations and engage with more gender sensitive policies and specifically include programmatic activity for access to SRH provision during health emergencies .
Availability of data and materials
Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.
An unsafe abortion is the termination of a pregnancy by people lacking the necessary skills, or in an environment lacking minimal medical standards, or both.
Corte Constitucional, Republica de Colombia, Sentencia C-355/06, (2006).
La Asamblea Legislativa de La Republica de El Salvador. Codigo Penal (1983).
Governo Federal do Brasil Regulamento Técnico sobre substâncias e medicamentos sujeitos a controle especial, (1998).
Aiken ARA, Scott JG, Gomperts R, Trussell J, Worrell M, Aiken CE. Requests for abortion in Latin America related to concern about Zika virus exposure. N Engl J Med. 2016;375(4):396–8.
Mayor S. Abortion requests increase in Latin America after Zika warning, figures show. BMJ (Clinical Research Ed). 2016;353:i3492–i.
Enemark C. Disease and security: natural plagues and biological weapons in East Asia: Routledge; 2007.
Davies SE. Securitizing infectious disease. Int Aff. 2008;84(2):295–313.
World Health Organization. International health regulations (2005). Geneva: WHO; 2005.
Heymann DL, Hodgson A, Sall AA, Freedman DO, Staples JE, Althabe F, et al. Zika virus and microcephaly: why is this situation a PHEIC? Lancet. 2016;387(10020):719–21.
World Health Organization. Fifth meeting of the Emergency Committee under the International Health Regulations (2005) regarding microcephaly and other neurological disorders and Zika virus WHO: WHO 2016 [Available from: http://www.who.int/mediacentre/news/statements/2016/zika-fifth-ec/en/.
de Araújo TVB, RAA X, Miranda-Filho DB, et al. Association between microcephaly, Zika virus infection, and other risk factors in Brazil: final report of a case-control study. Lancet Infect Dis. 2018;18(3):328–36.
Shapiro-Mendoza CK, Rice ME, Galang RR, Fulton AC, VanMaldeghem K, Prado MV, et al. Pregnancy outcomes after maternal Zika virus infection during pregnancy-US territories, January 1, 2016-April 25, 2017. MMWR Morb Mortal Wkly Rep. 2017;66(23):615–21.
Hoen B, Schaub B, Funk AL, Ardillon V, Boullard M, Cabié A, et al. Pregnancy outcomes after ZIKV infection in French territories in the Americas. N Engl J Med. 2018;378(11):985–94.
Honein MA. Recognizing the global impact of Zika virus infection during pregnancy. N Engl J Med. 2018;378(11):1055–6.
Brasil PPJJ, Moreira ME, et al. Zika virus infection in pregnant women in Rio de Janeiro. N Engl J Med. 2016;375(24):2321–34.
Yakob L, Walker T. Zika virus outbreak in the Americas: the need for novel mosquito control methods. Lancet Glob Health. 2016;4(3):e148–e9.
Wenham C, Farias DB. Securitizing Zika: The case of Brazil. Security Dialogue. 2019. https://doi.org/10.1177/0967010619856458.
Coast E, Norris A, Moore A, Freeman E. Trajectories of women's abortion-related care: a conceptual framework. Soc Sci Med. 2018;200:199–210.
Governo Federal Do Brasil, Codigo Penal Brasil, Brazilian Penal Code (1988).
Conselho Federal de Medecina, Dispõe Sobre o Diagnóstico de Anencefalia para a Antecipação Terapêutica do Parto e Dá Outras Providências, (2012).
La Asamblea Legislativa de La Republica de El Salvador.. Codigo Penal. El Salvador 1997.
Gies H, The rape survivor facing 20 years in jail lays bare El Salvador's war on women, new statesman, 14th November 2018, https://www.newstatesman.com/politics/feminism/2018/11/rape-survivor-facing-20-years-jail-lays-bare-el-salvador-s-war-women
Diniz D, Medeiros M, Madeiro A. Pesquisa Nacional de Aborto 2016. Ciência Saúde Coletiva. 2017;22(2):653–60.
Marteleto LJ, Weitzman A, Coutinho RZ, Valongueiro Alves S. Women's reproductive intentions and behaviors during the Zika epidemic in Brazil. Popul Dev Rev. 2017;43(2):199–227.
Sedgh G, JB SS, Bankole A, Popinchalk A, Ganatra B, et al. Abortion incidence between 1990 and 2014: global, regional, and subregional levels and trends. Lancet. 2016;39(10041):16–22.
Ganatra B, CG CR, Johnson BR, Tunçalp Ö, Assifi A, et al. Global, regional, and subregional classification of abortions by safety, 2010–14: estimates from a Bayesian hierarchical model. Lancet. 2017;390:2372–81.
Say L, DC AG, Tunçalp Ö, Moller A-B, Daniels J, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health. 2014;2(6):e323–e33.
Goveno Federal do Brasil. Atenção humanizada ao abortamento. In: Saúde. Md, editor. 2016.
Roa M. Zika virus outbreak: reproductive health and rights in Latin America. Philadelphia, Pennsylvania: Lancet; 2016. p. 843-.
Guttmacher Institute. Unintended Pregnancy and Induced Abortion in Colombia 2013 [Available from: www.guttmacher.org/fact-sheet/unintended-pregnancy-and-induced-abortion-colombia.
Lyman M, Mpofu JJ, Soud F, Oduyebo T, Ellington S, Schlough GW, et al. Maternal and perinatal outcomes in pregnant women with suspected Ebola virus disease in Sierra Leone, 2014. Int J Gynecol Obstet. 2018.
McGinn T, Casey SE. Why don’t humanitarian organizations provide safe abortion services? Confl Heal. 2016;10(1):8.
Barot S. The benefits of investing in international family planning and the price of slashing funding. Guttmacher Policy Rev. 2017;20:1–4.
Baena de Moraes Lopes MH, Gouveia Vilela MF, Marques D, Silva EM. Zika virus infection in Brazil and its repercussions on reproductive health. J Commun Healthc. 2018;11(1):62–8.
Ali M, Miller K, Folz R, Johnson BR Jr, Kiarie J. Study protocol on establishment of sentinel sites network for contraceptive and abortion trends, needs and utilization of services in Zika virus affected countries. Reprod Health. 2017;14:1–6.
Ministerio de Salud, Colombia. Lineamientos para la gestión de los planes de contingencia para fiebre Zika y atención clínica en embarazadas con infección por ZIKV y pacientes con complicaciones neurológicas y recomendaciones especiales. Actualización de la circular 043 de 2015. Bogota, D.C., 2016.
Vélez ACG, Diniz SG. Inequality, Zika epidemics, and the lack of reproductive rights in Latin America. Reprod Health Matters. 2016;24(48):57–61.
Gobierno de El Salvador. Gobierno intensifica acciones para combatir el virus del Zika 2016 [Available from: http://www.presidencia.gob.sv/gobierno-intensifica-acciones-para-combatir-el-virus-del-zika/.
Amarillo CR. Aegypti: Ideología de género, feminismo y extinción. Sex, salud soc (Rio J). 2017;(27):199–219.
Diniz D, Medeiros M, Madeiro A. Brazilian women avoiding pregnancy during Zika epidemic. J Fam Plann Reprod Health Care. 2017;43(1):80.
Carabali M, Austin N, King NB, Kaufman JS. The Zika epidemic and abortion in Latin America: a scoping review. Glob Health Res Policy. 2018;3:15.
Castro MCHQ, Carvalho LR, et al. Implications of Zika virus and congenital Zika syndrome for the number of live births in Brazil. Proc Natl Acad Sci U S A. 2018;115(24):6177–82.
Baum P, Fiastro A, Kunselman S, Vega C, Ricardo C, Galli B, et al. Ensuring a rights-based health sector response to women affected by Zika. Cadernos de Saude Publica. 2016;32:5.
Ministerio de Salud, Colombia. Lineamientos provisionales para el aborfaje clinico de gestantes expuesta al virus zika en Colombia Bogota, D.C., 2016.
Rasanathan JJK, MacCarthy S, Diniz D, Torreele E, Gruskin S. Engaging human rights in the response to the evolving Zika virus epidemic. Am J Public Health. 2017;107(4):525–31.
Center for Reproductive Rights. Unheard voices: Womens' experiences with Zika: the global response. New York; 2018.
Anderson E. Gender, HIV and risk: navigating structural violence: Springer; 2015.
Luna F. Public health agencies’ obligations and the case of Zika. Bioethics. 2017;31(8):575–81.
Nunes J, Pimenta DN. A epidemia de Zika e os limites da saude global. Lua Nova: Revista de Cultura e Política. 2016:21–46.
Lesser J, Kitron U. The social geography of Zika in Brazil: Brazil’s Zika epidemic has placed new and added pressure on Brazil’s public health system, but much about the outbreak is very old. NACLA Rep Am. 2016;48(2):123–9.
Johnson C. Pregnant woman versus mosquito: a feminist epidemiology of Zika virus. J Int Polit Theo. 2017;13(2):233–50.
Dreweke J. Countering Zika globally and in the United States: Women’s right to self-determination must be central Guttmacher policy review, vol. 19; 2016.
Davies SE, Bennett B. A gendered human rights analysis of Ebola and Zika: locating gender in global health emergencies. Int Aff. 2016;92(5):1041–60.
Moeller K. HuffPost [Internet]. The Blog: Huff Post. 2016. Available from: https://www.huffingtonpost.com/kathryn-moeller/zika-pregnancy-and-the-em_b_9128762.html.
G1. 70,3% dos domicílios do país têm saneamento adequado, aponta IBGE. O Globo. 2013 29th November 2013 http://g1.globo.com/brasil/noticia/2013/11/703-dos-domicilios-do-pais-tem-saneamento-adequado-aponta-ibge.html.
Jansen CC, Beebe NW. The dengue vector Aedes aegypti: what comes next. Microbes Infect. 2010;12(4):270–9.
Reiter P. Control of urban Zika vectors: should we return to the successful PAHO/WHO strategy? PLoS Negl Trop Dis. 2016;10(6):e0004769.
Riggirozzi P. The campaign to eradicate Zika has trampled over women's rights. The independent. 2017 11th February 2017.
Souza WVAM, Vazquez E, et al. Microcephaly epidemic related to the Zika virus and living conditions in Recife, Northeast Brazil. BMC Public Health. 2018;18(1):130.
Gostin LO, Friedman EA. A retrospective and prospective analysis of the west African Ebola virus disease epidemic: robust national health systems at the foundation and an empowered WHO at the apex. Lancet. 2015;385(9980):1902–9.
Shoman H, Karafillakis E, Rawaf S. The link between the west African Ebola outbreak and health systems in Guinea, Liberia and Sierra Leone: a systematic review. Glob Health. 2017;13(1):1.
Hennigan T. Brazil struggles to cope with Zika epidemic. BMJ. 2016;352(8047):i1226-i.
Rohr LK, Valongueiro STVBA. Delivery care and the inadequacy of the obstetric care network in Pernambuco. Rev Bras Saude Mater Infant. 2016;16(4):447–55.
Assunção MS Soares R, Serrano I. A Superlotação das Maternidades em Pernambuco no contexto atual da Política de Saúde. Serviço Social em Revista. 2014.
Araújo TVB. Delays in access to care for abortion-related complications: the experience of women in Northeast Brazil. Cad Saúde Pública. 2018;34(6).
Bearak J, Popinchalk A, Alkema L, Sedgh G. Global, regional, and subregional trends in unintended pregnancy and its outcomes from 1990 to 2014: estimates from a Bayesian hierarchical model. Lancet Glob Health. 2018;6(4):e380–e9.
Harris LH, Silverman NS, Marshall MF. The paradigm of the paradox: women, pregnant women, and the unequal burdens of the Zika virus pandemic. Am J Bioeth. 2016;16(5):1–4.
Davies SE, Youde J. The IHR (2005), disease surveillance, and the individual in Global Health politics. Int J Hum Rights. 2013;17(1):133–51.
World Health Organization. Emergency Resposne framework. In: Humanitarian health action. Geneva: WHO; 2017.
de Campos TC. Zika, public health, and the distraction of abortion. Med Health Care Philos. 2017;20(3):443–6.
El Espectador. "Todas las embarazadas con zika tienen la opción de abortar”:. El Espectador 2016 21st January 2016.
Prata ARS, Pedroso D, Menezes G, Drezett J, Torres JHR, Bonfim JRA, et al. Juridical perspectives of interruption of pregnancy with zika virus infection regarding medical emotional and social consequences. J Hum Growth Dev. 2018;28(1):77–81.
CoLatino G. El Zika y el embarazo y los derechos humanos: Diario CoLatino; 2016.
Davies SE, Harman S, Manjoo R, Tanyag M, Wenham C. Why it must be a feminist global health agenda. Lancet. 2019;393(10171):601–3.
Supremo Tribunal Federal Defensores públicos questionam lei sobre combate a doenças transmitidas pelo Aedes aegypti, (2016).
Diniz D, Gumieri S, Bevilacqua BG, Cook RJ, Dickens BM. Zika virus infection in Brazil and human rights obligations. Int J Gynecol Obstet. 2017;136(1):105–10.
Galli B, Deslandes S. Threats of retrocession in sexual and reproductive health policies in Brazil during the Zika epidemic. Cadernos De Saude Publica. 2016;32(4):e00031116-e.
The authors wish to acknowledge the participants of the workshop “Zika and the Regulation of Health Emergencies: Medical Abortion in Brazil, Colombia and El Salvador”, Thursday 20th and Friday 21st September 2018, Rio de Janeiro.
Funding for this project comes from Wellcome Trust 210308/Z/18/Z, Wellcome Trust has had no input into the design, analysis or interpretation of this paper.
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