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Zika Virus Outbreak and the Poor Brazilian Family Planning Program.

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 series3 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 shouldwait at least 8weeks 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 8weeks 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 Editorial