The Cascadia region is low on the Zika list, with only a handful of cases to date. Currently, neither of the two mosquito species that carry Zika lives in Cascadia, nor are they expected to arrive soon, even with climate change expanding mosquitoes’ habitat. So, the primary risk to residents of British Columbia, Oregon, and Washington comes from travel or sexual contact with infected persons who themselves have traveled.
Even so, with mosquito-borne infection likely in other states starting this summer, it only makes sense to safeguard Cascadia residents against possible harms. And since (with rare exceptions) the most devastating and lasting harms from Zika occur during pregnancy, an obvious way to reduce harm is to ensure that women at risk of exposure can time their pregnancies to avoid that risk.
The most powerful means we may have to prevent lifetimes of suffering from Zika is to make the very best and most reliable contraceptives—IUDs and implants—available and affordable to all women who want them. And we have the power to do that: a one-time system upgrade of family planning services could make the difference.
The Zika threat: From bad to worse
As babies born from Zika-infected pregnancies age and researchers can learn more, the news about the disease’s developmental impacts is only growing worse. The virus works by attacking progenitor cells that produce neurons in the developing brain, both eroding parts of the brain that have already developed and preventing new structures from developing. This damages multiple brain lobes, including those that control thought, movement, and vision. As far as researchers have been able to determine, Zika can affect this damage at any point in a pregnancy.
Microcephaly is the most visible and dramatic form of damage from fetal Zika infection, and experts say that the brain damage associated with Zika microcephaly is particularly severe. Neurologist William Dobyns at the Seattle Children’s Center for Integrative Brain Research says it is the worst he’s seen in 30 years of practice. “In these kids with Zika, you see really severe microcephaly. The heads are probably minus five to six standard deviations below the norm, and that’s really small. If the appearance of the head seems problematic, the brain is worse…. The idea that these children are mildly handicapped is a fantasy.”
Dr. Edwin Trevathan, professor of neuroscience at Baylor University, concurs, “It’s safe to say almost all of them will require long-term, continual care.”
But microcephaly, which occurs in one to fourteen percent of infected pregnancies, is likely just the most dramatic and visible form of harm. Pathogens that impair fetal development typically produce a range of defects that depend on the severity and timing of infection, and the extent of invisible damage will become apparent only as babies born from infected pregnancies grow up. A Brazilian study suggests that Zika also causes spontaneous abortion or birth defects in 30 percent of infected pregnancies.
A question of careful timing or risky gambling
With Zika and pregnancy, timing is everything. For a woman who wants a child, the ability to time pregnancy lets her stack the odds in favor of a healthy baby. For example, she might choose to delay pregnancy because of expected travel, because she knows that people around her are infected, or because mosquito season is coming. And of course, for a woman who would rather not be pregnant, Zika offers a good reason to step up precautions. Similarly, it offers good reason for healthcare systems to quickly ramp up access to better birth control.
Today, almost half of US pregnancies are unintended—either unwanted or mistimed by the mother’s own report. Both Washington State and Oregon are close to the national average, with approximately 60,000 and 30,000 unexpected pregnancies respectively each year. Fueling this trend, most American couples, to a greater or lesser degree, play reproductive roulette by relying on early to mid-20th-century contraceptive technologies: pills and barriers have pregnancy rates ranging from 1 in 11 to 1 in 4 because they are notoriously hard to use with perfect consistency and timing.
As the first wave of Zika moves through the United States, that will mean many American families are also playing Zika-pregnancy roulette—including Cascadian women who travel or who have sex with men who do. This summer, thousands of Americans plan to attend the Rio Olympics, some of whom will carry the Zika virus home. In addition, the first mosquito-borne cases are expected in southern states. The result could be a wave of brief infections with lifetime consequences. It doesn’t have to be that way.
Better birth control would reduce everyone’s risk
Three state-of-the-art “get it and forget it” contraceptives for women work twenty times better than the pill. Each has an annual failure rate below 1 in 500, is safe for young and single women, and offers a rapid return to normal fertility. Each also has a different appeal: the copper IUD is completely hormone-free; the hormonal IUD offers lighter and less frequent periods; and the implant is almost as easy as getting a shot. These methods offer contraception that, for the first time in human history, is truly reliable and reversible—and they also are the easiest ever to use. Once settled into place they require no action for years, unless a couple wants a pregnancy.
If we wanted to protect families against the Zika wave or future pandemics that might cause fetal harm, like influenza, we know how to do it. All it would take is a simple, one-time upgrade of our healthcare system, making state-of-the-art IUDs and implants (already free under Obamacare) available, the same day requested, in every setting that serves women of childbearing age. A second change, one that is overdue in Washington State, would allow pharmacists to prescribe birth control pills, as Oregon and California have permitted since 2015. In fact, research suggests that women and families would do even better if birth control pills were available over the counter.
Giving women better tools to align their pregnancy intentions with their actual lives can benefit mothers and babies in many ways beyond helping to avoid infected pregnancy. Pregnancy planning and preconception care help prospective mothers to avoid stressors and toxins that can harm the fetal nervous system during the weeks before most women would suspect an unplanned pregnancy.
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A statewide upgrade of family planning services is underway in Delaware right now, thanks to the vision of Governor Jack Markell. Markell sees the program as a powerful way to combat poverty and give kids the best starts in life. As part of the upgrade, Delaware Contraceptive Access Now is adopting an Oregon model of screening for pregnancy intentions, known as “One Key Question.” It’s simple: the one key question with which a provider opens a conversation about contraception or pre-conception care is, “Would you like to become pregnant in the next year?”
Research in parts of Colorado and Missouri has shown that increasing access to IUDs and implants can be a radical game-changer for teens. Unexpected and unwanted pregnancy plummets, as does abortion. Suddenly, women of all ages are better able to prepare so they can welcome a new child under the best circumstances available to them.
Here in the Northwest, Oregon is leading the country by making the pill available from pharmacists and by training primary care doctors to screen for pregnancy intentions. Billing codes have been updated so that providers serving Medicaid patients can get reimbursement for contraceptive counseling. And the state is monitoring whether women at high risk for mistimed or unwanted pregnancy are actually receiving modern contraceptives.
The Washington opportunity
Will Washington join in leading this transition to intentional parenthood? And will it get out ahead of Zika? That remains to be seen. Under Obamacare, Medicaid Transformation Projects that improve health outcomes without raising costs will be rolled out across Washington in coming months and years. But prevention of unintended pregnancy disappeared from the state’s Medicaid Transformation Tool Kit between the March and April updates, replaced by more ambiguous language about maternal health.
Yet Zika brings into focus precisely how reproductive empowerment can dramatically improve and even save lives. Nationally in the United States, the Center for American Progress estimates that two million pregnant women will be at risk of Zika infection this year. We can assume by national averages that approximately half of those pregnancies will be unintended—and that given better access to better birth control, some of those women would have chosen to time their pregnancies differently.
Intentional parenthood may be one of the single most powerful factors in creating a healthy environment for fetal development and early childhood. It offers primary prevention—a way for prospective parents to manage risks and optimize circumstances for their children, themselves, and their families before harm begins.
As climate impacts and globalization disrupt lives and transmit pathogens from one region to another, some suffering is inevitable. But some is not. The power to prevent lifetimes of suffering has been placed in our hands. Why not offer prospective parents every means possible to time their pregnancies and stack the odds in favor of healthy children?