Advocacy & Health Policy: Zika in Puerto Rico: A Sign of What’s to Come in the United States

By Kristyn Brandi, MD, Family Planning Fellow at Boston Medical Center

There have been 16 babies born in the United States infected with the Zika virus. As more cases arise in the US, the Zika epidemic increasingly becomes a cause for concern. There are about 521 cases of Zika-infected pregnancies in the US territories, which include Puerto Rico, American Samoa, and the US Virgin Islands. The majority of these cases have been found in Puerto Rico, where local transmission is already a reality. Information among the people about Zika is scarce, and women have limited resources.

In July 2016, I traveled to Puerto Rico through my Family Planning Fellowship and spoke to women about their knowledge of the virus and barriers to education. Many women i spoke to were not worried about Zika due to a long history of mosquito-borne infections in Puerto Rico. To them, Zika is just another one. While clinics do give out information about Zika, some members of the public may not trust their governmental sources.

On the other hand, there are women in Puerto Rico who are very concerned. My friend’s sister is pregnant and very afraid. She lives in Puerto Rico, and since learning about her pregnancy, she has remained homebound. She protects herself with long clothes and is strongly considering moving to the States until she delivers. 

Effectively addressing Zika is a challenge for many reasons. Economically, Puerto Rico is struggling, and many who wish to expand their families don’t see the US territory as a place to do so. Before I was born, my parents looked at the economic situation and struggling schools and decided to move to the States to raise me—that was 30 years ago. Since Puerto Rican citizens are US citizens, they can come and go as they please. Many women may see Zika as the last straw in their attempt to stay in Puerto Rico.  

Reproductive age women also do not have access to all contraceptive options available in the continental US, leaving them with two options—oral contraceptives or sterilization. Options like long-acting reversible contraception (LARC) are rarely available in Puerto Rican clinics. The island has a troubling history of contraceptive coercion by doctors and researchers (both US and Puerto Rican). The first birth control pill, Enovoid, was tested on Puerto Rican women during a time when limited informed consent and coerced sterilization were the mainstay of care. Given the history, it is understandable that women may be hesitant when the government recommends they use LARC.

Addressing Zika in Puerto Rico is a complex issue with several critical problems at its core:

  • How to prevent Zika transmission—both by mosquitoes and sexual transmission
  • How to properly diagnose pregnant women
  • How to care for pregnant women infected with Zika, including options like counseling

We cannot yet completely prevent Zika infection, but we can certainly work to minimize the risk of unintended pregnancy by using contraception. While women may be skeptical of their means, public health organizations play an important role in educating women about their options, both to prevent pregnancy and to have a healthy planned pregnancy. 

Puerto Rico’s situation is thankfully improving, but there is still much to be done in the mainland United States. Providers need to emphasize to their patients that there are ways to test for Zika in pregnancy, but that there are also many preventative measures they can take. Fellows doing generalist work should be offering all types of contraception for same-day placement in their clinics so that women who initiate care can be immediately protected. Likewise, they should have access to information about their options if they are pregnant, including Zika testing, information about birth defects associated with Zika, high-risk pregnancy doctors, and abortion services.   

What Can You Do?

ACOG has taken a big step to help in this effort through a recent donation of over $100,000 to the CDC Foundation’s Zika initiative. But the United States cannot count on private donations alone.

Fellows must encourage their local and state governments to press Congress to act on passing comprehensive legislation that helps women and their families in all aspects of Zika care: preventive care including contraception, prenatal care, abortion services, and efforts to develop a vaccine. Without a group effort, we may be seeing Zika as a women’s health crisis for years to come.

Visit ACOG’s Zika webpage for up-to-date resources.

Learn more about the Zika virus on the CDC website.

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