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09/14/2016

Pregnancy, stigma, and moral responsibility in the Zika epidemic

by Kelly McBride Folkers, BS

Pregnancy comes with great moral responsibility from mother to future child. A healthy pregnancy requires that pregnant women abstain from certain behaviors, like eating unpasteurized foods and drinking excessive amounts of alcohol. These decisions affect the wellbeing of the future child. But in addition to bearing the responsibility for the healthy development of the woman’s individual child, pregnant women face social stigmatization during pregnancy. The world takes notice of pregnant women, and this attention can be as innocuous as offering a seat to a visibly pregnant woman on the subway. But it all too often results in social isolation, decreased physical activity, and when pregnant women report a lack of social support, higher incidence of depression and anxiety symptoms.

The scientific and public health communities are learning that the Zika virus is capable of more damage to the developing fetus than initially thought possible. I am researching the ethical implications of Zika’s impact on reproductive health decisions for my master’s thesis and co-wrote a public health guide on staying healthy while traveling to areas with active Zika transmission. As a result of my work, I am left with a fear that pregnant women bear not only a responsibility to their own health and that of their future child, but a social one that is wrongfully imposed upon them by public health officials to make the rest of us feel comfortable.

The social norms around pregnancy are unlikely to change, yet I empathize with the added stressors to pregnant women in Florida as Zika continues to spread in the United States. A recent New York Times article described the daily lives of pregnant women in south Florida, many of whom don’t leave their homes unless they are going to a doctor’s appointment. Some have even decided to head further north, to areas that aren’t active Zika transmission zones, for the duration of their pregnancies.

Zika causes severe birth defects to the developing fetus such as microcephaly and other neurodevelopmental concerns. The photographic evidence of these risks are sensationally distributed in every news outlet almost daily. Those who can’t afford to work from home or temporarily relocate to a cooler climate face a grave risk to their pregnancy. Even when applied meticulously according to the manufacturer’s instructions, insect repellent only works so well, and people can get still bitten if just a sliver of skin is exposed. The Aedes aegypti mosquitos feed all day long, making it even more difficult to avoid them. Mosquitos seem to like some people more than others; I can’t go into a backyard in the summer without getting eaten alive, whereas other people I know can survive a barbecue unscathed.

With efforts under way to cull the mosquito population through spraying and the potential release of genetically modified male mosquitos that would not render their offspring viable, local public health authorities have tacitly acknowledged that the U.S. outbreak of Zika is outside the control of individuals. Yet, as Congress has yet to pass a bill that would allocate funds toward halting Zika’s spread, pregnant women and their providers are asked to bear the responsibility of ensuring healthy fetal development in areas where that is threatened by a virus outside of their control.

Paternalism, or the idea that personal liberties can be limited for some greater public good, is the ethical justification for many public health decisions. Health care providers apply the same paternalistic approach to the care of pregnant women by instructing pregnant women not to drink, smoke, or eat certain foods, and instructing them to take folic acid and to get regular medical check-ups. Specific to Zika, the Centers for Disease Control & Prevention advises pregnant women not to travel to areas where mosquitos are actively transmitting the virus. The CDC also recommends that pregnant women at risk for Zika virus infection receive additional ultrasounds and seek out clinical screening for Zika, placing a responsibility on these women and their providers to take the lead in halting the virus’s spread.

These paternalistic approaches specific to pregnant women have the greater public goal of preventing infants from being born with severe Zika-related birth defects, and this is a worthy aim. Public health officials, it seems, are placing a moral obligation on pregnant women to prevent the effects of Zika from harming the next generation of people. But these women don’t have much help. Economically disadvantaged pregnant women might not be able to afford additional doctors’ visits or to stay inside all day to work. In in its bulletin on treating Zika, Medicaid will cover family planning counseling and the cost of condoms, but there is no mention of access to diagnostic testing in its informational bulletin about Zika.

All pregnant women already face an incredible amount of public scrutiny for their behaviors. I would bet that most people make a value judgment if they see a pregnant woman drinking a glass of wine – a choice that, when made responsibly and infrequently, is unlikely to have a deleterious effect on a fetus. Already, society often blames pregnancy women for problems in their children. A child born with fetal alcohol syndrome, or drug withdrawal, or even HIV and hepatitis usually brings scorn against the mother and in some states might even bring a criminal arrest. I fear that the same kinds of judgments will be made if a visibly pregnant woman in Florida leaves her house. Will social scorn and stigma befall a woman simply for being in a place where there is a risk of exposure? Will neonatal ICUs call child protective services on women who are deemed to have used an insufficient amount of insect repellant?

To be sure, the analogy between Zika and drinking is imperfect. Certainly exposure to Zika is not a positive causative action such as drinking and taking drugs, but exposure is, to a limited extent, controllable. Thus, the social costs pregnant women face are a strong analogy. There are few other parts of our personal lives where social judgment of our actions is not only accepted, but expected. The limitation to personal freedom of abstaining from excessive alcohol for nine months is a small sacrifice compared to asking someone to remain under house arrest for nine months.

Certainly, women of childbearing age should seek out testing for the Zika virus if they are planning a pregnancy, which is free in Florida. This is the relevant information from the daily press Zika updates: “Pregnant women can contact their local county health department for Zika risk assessment and testing hours and information. A Zika risk assessment will be conducted by county health department staff and blood and/or urine samples may be collected and sent to labs for testing. It may take one to two weeks to receive results.” Labs, however, are overwhelmed and stretched thin at this point.

While women have the physical ability to choose to engage in certain behaviors risky to their fetus, our society has deemed that they lack the moral freedom to make such risky choices for the nine months of gestation. The physical burdens of gestation are not made easier by the scrutiny and social shunning of strangers. As the Zika virus puts pregnant women in the spotlight, it is time for all of us to question the dehumanizing stigma that we place on pregnancy.

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