Learnings from zika and reproductive rights in africa

The late termination of pregnancies displaying severe foetal anomalies is both an ethically and morally challenging dilemma. The outbreak of the mosquito born Zika virus in South America last year is a good example of this dilemma faced by under resourced countries. What started out as a question about containment and the causal relationship between the Zika virus and microcephaly, quickly escalated into an issue about access to reproductive health and women’s right to abortion.

Declared an international public health emergency by the World Health Organisation, the United States Centre for Disease Control and Prevention (CDC) have concluded that the Zika virus is indeed directly responsible for the exponential birth of babies born in South America with severe neurological defects.

According to Sylvester Chima, Professor of Medical Ethics at the University of KwaZulu-Natal and speaker at the 6th annual Health Exhibition & Congress 2016, doctors have a legal and ethical obligation to provide an accurate antenatal diagnosis to enable informed decision making. "With a duty to protect women’s autonomy and preservation of scarce healthcare resources on one hand, but the foetuses right to personhood and the doctor’s moral obligation to society on the other, counselling women to make an informed decision is a real challenge."

Chima explains that, based on MRI scans, the brain stem and the cerebellum of babies born with microcephaly are severely deformed, as has been the case with the Zika virus. "These parts of the brain oversee bodily functions that don’t require active thought. Affected children will need constant care for the remainder of their lives. Health professionals are unable to confirm the life expectancy of a baby with microcephaly who is severely intellectually impaired, and the prognosis is not a good one."

Abortion is illegal under any circumstances in seven South American countries, including El Salvador who has been the hardest hit by Zika after Brazil. In addition, abortion is not permitted for any reason in eleven African countries. With regards to South Africa, the Choice on Termination of Pregnancy Act 1996, allows women in South Africa to terminate pregnancies with severe congenital anomalies such as those caused by the Zika virus i.e. microcephaly, if diagnosed before delivery up to 40 weeks of pregnancy ( late termination).

"In countries with restrictive laws, women carrying an abnormal foetus will be forced to deliver the baby," says Chima. "In these cases, developmentally challenged babies and children generally require extensive and lifelong support, which can add greater resource allocation issues to already under-resourced healthcare systems."

He adds there is a moral obligation on doctors to prevent waste of healthcare resources. This may occur when scarce technological modalities such as artificial ventilations and incubation is deployed in the futile management of commonly lethal foetal anomalies, thereby denying access to other neonates who maybe are amenable to treatment."

Chima is however hopeful. "The United Nations has called access to abortion a human right. Termination of pregnancy for severe foetal anomalies is supported by international laws against cruel and inhuman punishment and is enshrined in the International Covenant on Civil and Political Rights."

In Africa, the United Nations Human Rights Committee findings are consistent with the protocol to the African Charter on the Rights of Women. This obligates African countries as signatories to the African Charter, to liberalize abortion law and provide mechanisms for easy access, so that women can exercise the right to terminate.

While some signatories to the African Charter display relatively liberal abortion laws, African women unfortunately still suffer under the unfair burden of restricted access to contraception and safe abortions. According to the World Health Organisations a safe abortion is deemed one performed by a medical professional with the necessary skills and in an environment conforms to minimum medical standards. Of the 6.4 million abortions carried out in Africa in 2008, only 3% were performed under safe conditions[1].

According to the Guttmacher Institute unsafe abortions resulted in at least 9% of maternal deaths of African women in 2014. "It’s argued that many African countries would benefit by liberalising abortion laws and minimizing the incidence of unsafe abortions. This way African countries can improve maternal mortality and morbidity associated with restrictive abortions laws," says Chima.

Furthermore, Chima says that, "while diagnostic modalities have drastically improved prenatal diagnosis in developed countries, the availability of these resources and expertise remains scarce in poorer nations. The situation is exacerbated in Africa, where women in certain countries suffer limited access to reproductive healthcare."

"The issue raised by the Zika virus is that the women’s right to reproductive health and the denial of abortion in these extreme cases impacts on fundamental human rights. We should look at this case and reflect on our approach to the allocation of healthcare resources, the management of foetal abnormalities in Africa and our ethical and legal approach to late termination of such pregnancies," concludes Chima.

Chima will be speaking at the Ethics, Human Rights and Medical Law conference, which will form part of the 6th annual Africa Health Exhibition & Congress 2016 taking place 8-10 June 2016 at the Gallagher Convention Centre in Johannesburg, South Africa. More than 7000 regional and international healthcare professionals and medical experts are expected to attend the event.

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