Using Uruguay’s harm reduction approach to allow women with Zika infection to have legal abortions & WHO advice on Zika

Dr Leonel Briozzo, Vice Minister of Public Health, Uruguay, who introduced a harm reduction policy for reducing the risk of unsafe abortions before the country’s abortion law was reformed, has suggested a similar policy in relation to Zika infection. With abortion, the policy was to invite women considering abortion to attend a counselling session at the main maternity hospital, where most women used to present for post-abortion treatment for complications.While acknowledging abortion as a crime (except in cases of rape and incest and to preserve the health of the woman), they provided “before” and “after,” support. At the “before visit,” a physician would confirm pregnancy and how far advanced it was, identify any pathological conditions, and determine whether the woman qualified for a lawful abortion. If she did, abortion was provided upon request. If not, women would be given an overview of different methods of abortion and their safety in a backstreet setting. Women mostly decided to self-use misoprostol and had to find out where to obtain it on their own. They were encouraged to return after they aborted for confirmation it was complete and there were no complications, and were also offered contraception. The Health Minister at the time approved the policy when it became clear that complications from unsafe abortions dropped substantially, none were severe, and there were no maternal deaths (the hospital had previously seen 10 per year). It took eight more years before Uruguay legalized abortion, but meanwhile the government enacted a regulation to expand the model to all public sector facilities.Briozzo’ group, Iniciativas Sanitarias, also worked with international organizations to replicate this model in nine other countries – all of them larger, poorer and more socially conservative than Uruguay, including Uganda and Tanzania. In none, as of yet, has the model reformed the law or been scaled up to national level, but advocates say it has had a clear impact on unsafe abortion in many of the communities where it was piloted. It has also emboldened providers in those places to speak out publicly.Giselle Carino, director of IPPF Western Hemisphere Region said: “We think the Uruguay Model can open up possibilities for women where Zika is a threat – in Brazil, in Central America.” After all, she says, it isn’t that Ministries of Health aren’t concerned about unsafe abortion, which accounts for at least 10% of maternal deaths in Latin America and the Caribbean and imposes a heavy cost on health systems. The model would provide them with the means to take action without engaging the law.SOURCE/PHOTO: New York Times, by Patrick Adams, 28 June 2016***WHO advice: Olympic Games, Zika infection, pregnancy and safer sexThe Lancet reports that on 20 May 2016, 150 physicians, bioethicists, and scientists from several countries (including Brazil) posted an open letter suggesting WHO exert pressure on Olympics authorities to delay or relocate the Rio de Janeiro Games in August because of public health concerns over the risk of Zika virus infection for tourists and athletes. The same concern was raised in 2013 about the risk of dengue infection for tourists and athletes intending to travel to Brazil during the 2014 World Cup. Afterwards, the reported number of dengue cases among tourists after the Games was only three. The mosquito that transmits Zika has a strong seasonal pattern, with highest abundance in summer in Rio (Jan–Feb) and lowest in winter (July–Aug). A study they report estimated that the risk of Zika virus infection is therefore more than 15 times less than that for dengue.WHO says that based on the current assessment of Zika virus circulating in almost 60 countries globally and 39 countries in the Americas, there is no public health justification for postponing or cancelling the Games.However, WHO still advises pregnant women not to travel to areas with ongoing Zika virus transmission, including Rio de Janeiro. They also say that pregnant women’s sex partners returning from areas with circulating virus should be counselled to practise safer sex or abstain throughout the pregnancy.Others returning from areas where Zika virus is found should follow safe sex practices or abstain from sex for at least 8 weeks. This doubles the abstinence period WHO had previously advised after scientists found the virus lingers longer in blood and other body fluids, including semen, than previously thought. If a male partner has symptoms of Zika virus, the period for abstinence should be six months. The length of time the virus can be traced in saliva is still inconclusive.Source: WHO website, 28 May 2016 ; Lancet, E Massad et al, 2-8 July 2016