Pregnant Puerto Ricans Fearful of Zika

By Brenda Goodman, MA
WebMD Health News

Reviewed by Brunilda Nazario, MD

March 14, 2016 -- Ask pregnant women in Puerto Rico if they want a boy or a girl and you'll get an age-old answer: They don't care, as long as the baby is healthy.

But that statement carries new meaning in Puerto Rico these days. The news that Zika virus is being spread by the mosquitos here and infecting islanders -- including, at last count, 21 pregnant women --means the health of these women's unborn children could be stolen at any time with one bite from a pest that's lurking in their homes.

Some expectant moms have left the island rather than live with the threat.

Amanda Vaccaro, 27, left in February, when she was just a month away from her due date. She moved back to Ohio to live with her parents until after the baby, a girl she will name Grace, is born.

Her husband is in the Coast Guard and is stationed in Puerto Rico. He is still there as she plods through the last and most difficult weeks of her pregnancy.

"We couldn't live with ourselves if something happened by me staying there," she says.

Doctors believe that Zika infections may do the greatest damage during the early weeks of pregnancy, when a baby's organs are still forming. Vaccaro was already in her third trimester when she decided to leave.

When she talked to her doctor about the risks, "He couldn't really tell me yes or no because they don't really have too much information on the virus."

Because many people who get Zika won't have symptoms, Vaccaro also took a blood test before she left to find out if she's been exposed to the virus. She still doesn't know the results.

She says several other Coast Guard moms have also decided to leave.

It wasn't what she wanted.

"I didn't want to be away from [my husband], so that was hard. We liked our doctor. Our nursery was there. Our home was there. It was really hard to decide," she says.

Leaving isn't an option for everyone, of course.

Ana Rius, MD, secretary of the Puerto Rico Department of Health, has advised women to consider delaying their pregnancies. That's harder than it sounds.

The majority of Puerto Ricans are Catholic, and family planning runs counter to their personal beliefs. The Pope recently made news by suggesting that birth control would be OK if used to slow the spread of Zika.

For women who do want to delay pregnancy, the most effective tools -- long-acting contraceptives --aren't easy to get here.

Seventy-five percent of pregnant women on the island are cared for by the Medicaid program, says Nabal Jose Bracero, MD, a fertility specialist who is the president of the local chapter of the American College of Obstetricians and Gynecologists.

Medicaid restrictions require doctors to get special permission before they can prescribe devices like IUDs and hormonal implants. It's even difficult, in some instances, to get coverage for a common surgery called a tubal ligation that prevents pregnancy by blocking a woman's fallopian tubes, Bracero says.

Bracero met with CDC Director Tom Frieden, MD, and the two men have hatched a plan to skirt Medicaid and other insurance requirements altogether by giving long-acting contraceptives to women on the island for free.

"I'm thinking of this like a war," Bracero says. "The first wave of attack against the Zika is going to be donated implants."

Their plan is modeled on a highly successful experiment in Colorado. There, the state health department of health offered teenagers and low-income women access to long-acting contraceptives at no charge. The rate of unplanned pregnancies in teenagers there plunged 40%. The abortion rate was cut by 42%.

It's unclear whether women will be as accepting of long-acting contraceptives in Puerto Rico.

One thing that is clear, Frieden says: Women are taking the threat seriously here.

"It's been clear that pregnant women are very motivated to reduce their risk of Zika," he says. "We had heard people are kind of lackadaisical about Zika because they saw dengue and chikungunya and they couldn't stop it. That's not what we're hearing from pregnant women. They're very concerned."

They're still hashing out the details.

And for the time being, most of the pregnancies on the island are unplanned.

That's what happened to Nadia Quinones, 30, who is 9 weeks pregnant with her second child.

Her pregnancy, she says, "was a surprise for everyone."

"Zika is very scary right now. I don't know what to do because there's not a lot of information around," she says.

The CDC and the Puerto Rico Department of Health are working on a public awareness campaign about Zika, but they are still testing it on focus groups to make sure they present the information in a culturally sensitive way.

Nadia lives in San Juan, and like many residents, she has mosquitoes living in her house. Last year, she got chikungunya, another mosquito-borne virus that causes a rash, all-over body pain, and debilitating fatigue.


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"It was awful. I couldn't get out of bed," she says.

She said she learned about Zika from watching the news.

She knows she needs to wear insect repellent and get rid of standing water around her house. She and her husband are using condoms during sex to further protect the baby.

Quinones heard about a program being offered through the federal government's Women, Infants, and Children program, or WIC. The WIC's focus normally includes helping low-income women eat healthy food during pregnancy, but in Puerto Rico, the WIC has also been tasked with getting the word out to pregnant women -- and they're offering assistance to everyone, regardless of income.

She sat in on one of the free information sessions that's being offered daily at a local mall, and she took home a tote bag with mosquito netting, a green can of Deep Woods Off, disks of larvicide to kill the mosquito in its early stages, three condoms, some pamphlets, and a thermometer. If she runs a fever, she knows she needs to go in for a blood test.

"I was very scared at the beginning, but then they told me they can send people to look at around the house to prevent, to see what they can do to help me so I can see what I can do not to get the virus," Quinones says. Health officials plan to send teams to the homes of pregnant women to install window screens, inspect and repair septic tanks, and look for mosquito breeding sites.

She's grateful for the assistance. Her doctor, she said, wasn't much help. He told her to take precautions against the virus but left it up to her to figure out what those were.

Camila Vargas, 22, also said she didn't get much information from her doctor -- actually, "none whatsoever."

She's 18 weeks pregnant with her first child. She said her mother and her aunt warned her about Zika after seeing it on the news. She had not heard about the help or supplies being offered through the WIC program.

She did her own research on the Internet and learned she needs to wear "long pants, long sleeves, and tennis shoes," she said, rolling her eyes. Being covered head to toe isn't exactly comfortable when you're pregnant in the tropics.

She is using mosquito repellent, a blend of lemon oils her mother makes for her. She wears DEET, too, but no more than 10%, because her research tells her more than that is too high.

But both the CDC and the WHO have recommended that travelers to Zika-affected areas wear a repellent with at least 20% DEET, which is safe to use during pregnancy.

Juan Castaner, MD, who is one of five high-risk pregnancy specialists on the island, also did his own research, trying to figure out how to best advise his patients.

He tells his patients to wear long-sleeved shirts and pants. He also refers them to an article by Consumer Reports that tested which repellents worked the best against the kind of mosquitoes that carry Zika. It's the most helpful thing he's seen.

He's testing all of his patients for Zika. He hasn't had any whose tests show they have it. He fears it's just a matter of time. Many of his patients are from the mainland U.S. or Europe. He tells them to leave Puerto Rico if they can.

"I think everyone is worried," he says.

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SOURCES: Amanda Vaccaro. Ana Rius, MD, secretary, Puerto Rico Department of Health, San Juan, PR. Nabal Jose Bracero, MD, obstetrician-gynecologist, chair, Puerto Rico section of the American College of Obstetricians and Gynecologists, San Juan, PR. Tom Frieden, MD, director, CDC, Atlanta. Juan Castaner, MD, maternal-fetal medicine specialist, San Juan, PR. Camila Vargas. Nadia Quinones.

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