The National Family Planning Policy was created in Brazil in 2007. It includes offering
eight free contraceptive methods (intrauterine device [IUD] with copper, progestogen-only
pill, combined pill, monthly injectable, depot medroxyprogesterone, diaphragm, male
and female condoms) and also some other oral and injectable contraceptives at reduced
prices at “popular” pharmacies. In the last decades, modern contraceptive methods
have been developed, such as levonorgestrel intrauterine system (IUS) and subdermal
implants, but these are not accessible to the majority of the Brazilian population
because they are not available (for free or at a low cost) in the national health
system.[1]
In 2015, a microcephaly outbreak began among Brazilian newborns, probably associated
with the Zika virus. Brazilian authorities estimate that ∼ 1,5 million cases of Zika
infection have occurred since the outbreak began, with almost 1,300 cases of microcephaly
subsequent to prenatal infection during pregnancy.[2] Although initially concentrated in the Northeast of Brazil, the virus has spread
throughout South America, the Caribbean and Puerto Rico. A published case series[3] of 1,511 live newborn infants with suspected Zika virus infection occurred during
pregnancy showed a sensitivity of 83% for microcephaly for diagnostic detection. However
there are Publications that Added additional clinical characteristics, including severe
intracranial calcifications, severe cortical malformations, ventriculomegaly, cerebellar
hypoplasia, and abnormal hypodensity of the white matter, but with normal head circumference,
creating a necessary expansion of the concept to become congenital Zika virus syndrome.[4]
In times of Zika virus outbreak and its fetal/neonatal effects, the World Health Organization
underlined the importance of affected countries to offer universal access to family
planning services. Margaret Chan, Director-General of the World Health Organization,
said “Latin America and the Caribbean have the highest proportion of unwanted pregnancies
in the world. In addition, these countries have high rates of sexual violence, and
restrictions on the use of emergency contraception and safe abortion prohibited by
law.” Therefore, the recommendation of health authorities for women residing in these
regions to postpone pregnancy for 1–2 years is unlikely to be achieved.[5]
The Centers for Disease Control and Prevention (CDC) recommend that people residing
in areas with current active Zika virus transmission might seriously consider delaying
their next pregnancy and, that women who have confirmed Zika virus disease should
wait at least 8 weeks after symptom onset before attempting conception. Men with Zika
virus disease should wait at least 6 months after symptom onset before attempting
conception. Women and men with possible exposure to Zika virus, but without clinical
illness consistent with Zika virus disease should wait at least 8 weeks after exposure
before attempting conception. Health care providers should discuss strategies to prevent
unintended pregnancy, including use of the most effective contraceptive methods.[6]
The most cost-effective contraceptive methods are the long acting reversible ones,
such as implants, IUD and IUS, because they are not user-dependent, have high rates
of satisfaction and have very low failure rates (less than 1% versus around 9% in
oral contraceptive pill users).[7]
[8] In Brazil, only the IUD with cooper is available to the population at no charge,
but it is still seldom used. In 2014, the Federação Brasileira das Associações de
Ginecologia e Obstetrícia (FEBRASGO) presented a proposal to the Brazilian Ministry
of Health for the inclusion of the levonorgestrel IUS and the etonogestrel implant
for teenagers, but the proposal was rejected on the grounds of high cost. The Brazilian
Government would pay around US$ 50 per implant (lasting up to 3 years) or levonorgestrel
IUS (lasting up to 5 years).[9] Undoubtedly, the Brazilian government is paying much more to treat the consequences
of the Zika virus syndrome.
The CDC undertook a study on Puerto Rico's contraceptive needs. The authors concluded
that local health policies were needed to ensure open access to effective contraception
for women who desire to avoid pregnancy during the Zika outbreak in Puerto Rico and
other affected areas. An increase of reimbursements and a reduction in costs for contraceptive
services would support access. Efforts to increase opportunities and education concerning
long acting reversible contraceptive method access are urgently needed.[10] The rates of unplanned pregnancy in Brazil are similar to those of Puerto Rico,
making these data and recommendations highly relevant also in Brazil.
The Zika virus outbreak has highlighted the poor quality of the national family planning
programs in Brazil and others Latin American countries. The majority of the Brazilian
women who are at risk for unplanned pregnancies live in areas with a high prevalence
of the Zika virus. Therefore, in order to decrease adverse pregnancy and birth outcomes
associated with Zika virus disease during pregnancy, crucial improvements need to
be made in providing full access for all women in the reproductive years to family
planning services and to long acting reversible contraceptive methods.[11]
