The Zika virus (ZIKV) epidemic is spreading: 67 countries are now reporting transmission, and over 2,000 cases of congenital Zika syndrome (CZS) have been confirmed.

The heaviest burden has been borne by those living where poverty, poor infrastructure, and lack of access to health services are common and the penetration of Aedes aegypti is high. Because most cases are asymptomatic, the most dramatic signs of the disease appear through the CZS cases. In spite of the need for disaggregated epidemiological data to understand transmission patterns and evaluate interventions in vulnerable populations, there is no reliable count of ZIKV cases by sex and ethnicity (1).

WHO’s interim guidance on pregnancy management in the context of a ZIKV infection includes recommendations for preventing and managing infection in pregnant women. Vector control is emphasised, as well as personal protection such as clothing, bed nets, repellents, and safe sex (2). These recommendations, duly relayed by health authorities, don’t always resonate in the poorest neighbourhoods of Brazil, El Salvador, and other affected countries, where the availability, practicality, and affordability of protective items are doubtful, and where safe sex is not always negotiable. When prevention fails, pregnant women and other women of reproductive age are faced with difficult decisions against a background of uncertainties.

Basic reproductive services may be lacking or inaccessible. In many cases, restrictive abortion laws curtail their ability to thwart the consequences of the virus for their health and that of their children.

El Salvador, a Central American country with a population of 7 million, most of whom are Roman Catholic or Evangelical Christians, has been hit by ZIKV. There have been an estimated 5,400 cases of ZIKV, 100 of which were in pregnant women. El Salvador has urged all women to delay pregnancy until 2018. In Central America it is estimated that 74% have access to contraceptives. With physicians across Central and Latin America urging women to postpone pregnancy because of ZIKV, Pope Francis said that using contraceptives could be a “lesser evil” when a baby would have a high risk of birth defects; but he added, “Abortion is not a lesser evil — it’s a crime. It is the deliberate taking of an innocent human life… It’s an absolute evil…Don’t confuse avoiding pregnancy with abortion.” (3)

The government of El Salvador has some of the strictest anti-abortion laws. Abortion is banned without exception, including after rape, incest, severely deformed foetus diagnosis, and when a woman’s life is in danger. Under Salvadoran law, doctors must report women whom they suspect of having induced an abortion. It is strictly illegal for doctors to provide abortion services, and to advise on how to procure them.

The Citizen Group for the Decriminalization of Therapeutic, Ethical, and Eugenic Abortion (CFDA), a local rights group, says the abortion ban causes maternal deaths by forcing women to undergo dangerous back street abortions. An estimated 35,000 clandestine abortions take place in El Salvador every year. The rights group says that scores of women have been wrongly convicted of murder and imprisoned when they in fact suffered miscarriages, stillbirths or pregnancy complications. Of the 147 women prosecuted for abortion-related crimes between 2000 and 2014, 25 remain in jail, with some serving sentences as long as 40 years, the CFDA says. The legal ban particularly affects poor women, who cannot travel abroad to private clinics (4).

Resistance to changes to the ban comes not only from the Catholic church and evangelical groups, but from conservative lawmakers and the left-wing ruling FMLN party that fears alienating voters.

Scenario

A woman, from one of the barrios of the capital, San Salvador, presents at a local clinic for her first prenatal visit when she is 20 weeks pregnant. She gives a history that is consistent with an acute ZIKV infection when she was 12 weeks pregnant. The doctor tests her for ZIKV and she has antibodies consistent with a past infection. A brain scan shows evidence of early calcifications. The doctor informs the patient of her findings and the consequences of ZIKV for the foetus. The woman is devastated. She has three other children less than seven years of age and her husband is a day labourer. The patient pleads with the doctor to give her advice on what she can do to prevent the birth. The doctor, who supports a woman’s right to choose and is a member of CFDA, knows that safe abortions can be performed within the city at a price that may be affordable to the woman.

• What should the doctor recommend?
• Should the doctor give the woman a set of choices that include an illegal act, punishable under the law?
• What if the patient cannot afford an in-country abortion?
• Does the doctor have a duty to her patient that transcends the law of the land?
• Does it matter what the doctor’s personal beliefs on abortion are?
• Does it matter that El Salvador is a democracy and a majority supports highly restrictive abortion laws?
• Does it matter that according to a recent Pan American Health Organization guidance document, all governments are bound by a duty to provide information, respect the right to choose, and provide access to comprehensive reproductive health care and social support to women affected by ZIKV and their children? (2)