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Thinking (Re)Productively

Providing family planning care in the context of Zika: a toolkit for providers from the US Office of Population Affairs

Christine Dehlendorf, Loretta Gavin, Susan Moskosky

The Zika virus is a newly emerging threat to women's reproductive health that is receiving increasing international and domestic attention. This virus can be passed from a pregnant woman to her fetus and cause microcephaly as well as other severe brain anomalies, and has also been linked to problems such as defects of the eye and pregnancy loss [[1], [2]]. Zika is transmitted both through the bites of Aedes species mosquitoes and through sex with a person who has been infected with Zika, and the virus has been circulating in South and Central America and the Caribbean (including Puerto Rico) since 2015. The first case of mosquito-borne transmission in the United States occurred in June 2016.

Given that Zika has implications for pregnancy outcomes and is transmitted through sexual contact, providers of contraceptive and other family planning services to individuals of reproductive age have a critically important role to play in mitigating the impact of this unusual public health challenge. The World Health Organization and the Centers for Disease Control and Prevention (CDC) recommend that women at risk of Zika infection should have ready access to contraceptive services, and that men and women of reproductive age receive counseling and information to allow them to make informed decisions about any plans for pregnancy [3]. Even Pope Francis has suggested that in the context of the Zika virus outbreak, women could use contraception to prevent a pregnancy [4]. Yet efforts to expand access to contraception in the context of Zika have lagged behind other equally important efforts, such as vector control, outreach to pregnant women, and testing.

The Office of Population Affairs (OPA) has developed a toolkit, entitled “Providing Family Planning Care for Non-Pregnant Women and Men of Reproductive Age in the Context of Zika: A Toolkit for Healthcare Providers,” with the goal of facilitating providers' ability to integrate counseling and services related to Zika into the care they provide. This toolkit is designed to help implement recent CDC recommendations for providing Zika-related care to nonpregnant women and men of reproductive age. The development of the toolkit is driven by abundant evidence that the act of publishing clinical guidelines alone is seldom enough to lead to implementation in practice [[5], [6]]. Other steps are needed to help providers operationalize the guidelines. This toolkit includes a variety of modules, including the following:

  • Basic information about Zika
  • Specific counseling considerations related to Zika
  • Provider job aids for counseling women and men about their risk for Zika and its implications
  • Client handouts that providers can use to educate and counsel about Zika
  • Community outreach materials to encourage more people to seek care
  • A compendium of research and clinical guidance on Zika

OPA emphasizes throughout the Zika toolkit that the goal of counseling about the risks associated with Zika is not to persuade clients to adopt certain behaviors or contraceptive methods, but rather to enable them to make informed, quality decisions that reflect their values and preferences, especially regarding contraceptive choice. This approach is grounded in the client-centered approach described in the CDC-OPA recommendations, Providing Quality Family Planning Services (2014) [7].

This toolkit is designed for use in areas where Zika is being actively transmitted by mosquito, as well as those where mosquito-borne transmission is not currently happening. In the latter areas, clients may still be at risk related to travel or sexual transmission. Specifically, the toolkit details the following roles for providers of family planning care in the context of Zika:

  • Help clients to consider how information about Zika and their risk may affect their reproductive health goals and behaviors.
  • Provide contraceptive services to those who wish to prevent or delay pregnancy, considering their Zika risk as one influence on their choice of a contraceptive method.
  • Provide condoms to men and women who are at risk for sexual transmission of Zika.
  • Counsel clients who are at risk of Zika infection and may become pregnant about how to reduce the risk of acquiring Zika before and during pregnancy.
  • Offer testing to women and men who are exposed to Zika virus and develop symptoms.

Zika counseling and education for women

The recommended process for providing care to a woman of reproductive age in the context of Zika begins with identifying her feelings about pregnancy now or in the near future (Fig. 1). Providers then perform a risk assessment to determine her current and future risk of Zika infection, based on her place of residence and previous and planned travel for both her and her partner(s). OPA recommends a two-step screening process due to the complexity of the risk profile, which includes geographic exposures, sexual exposures, use of mosquito bite prevention strategies, presence or absence of symptoms and risk for pregnancy. In the first step, clients are provided with basic questions by front office or nursing staff. In the case of women living in areas without local Zika transmission, these questions assess the past and future travel of the client and her partner(s), whereas for those living in areas with Zika transmission, the focus is on the use of strategies to prevent Zika infection. Based on the answer to these questions, the healthcare provider can then proceed with more specific questions to determine whether current or future risk exists, such as whether the client's or partner's travel was to an area with Zika (which can be facilitated by using maps located on the CDC's website at www.cdc.gov/zika/geo/active-countries.html) and whether women or their partner(s) experienced symptoms (as the presence of symptoms influences the time period during which it is recommended to avoid pregnancy).

Fig. 1 Opens large image

Fig. 1 Counseling for non-pregnant women of reproductive age.
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For many women who do not live in areas with Zika, this process will reveal no risk for the virus. In those cases, providers are encouraged to give basic Zika information to address the fact that women's risk of exposure can change, and then proceed with routine family planning care.

Providers can give education about the Zika virus and its implications to women who have an identified risk, and then supply individualized information based on client's degree and time frame of risk and pregnancy goals, drawing on the job aids and client education materials included in the toolkit. All women with Zika exposure or with partners with Zika exposure should be informed about the CDC recommendations for avoiding pregnancy after exposure, with the time frame depending on whether or not they or their partner experienced symptoms (see www.cdc.gov/zika for up-to-date recommendations). In some cases, this information may have the effect of altering a woman's feelings about pregnancy. For example, a woman who was ambivalent about pregnancy may decide, based on traveling to or living in an area with Zika, that she wishes to actively take steps to avoid pregnancy. Other women who desire pregnancy, but have specific, time-limited risk for Zika, may wish to temporarily delay attempts at conception according to the CDC recommendations.

Women who wish to use contraception to avoid pregnancy should be provided with client-centered contraceptive counseling focusing on their preferences in accordance with the CDC and OPA recommendations around provision of quality family planning services [7]. A person's risk of Zika may influence their contraceptive preferences. Those who are at greater risk due to geography, travel or partner risk factors may be more interested in using a highly effective method to prevent an undesired pregnancy. At the same time, clients will continue to have preferences about other method characteristics that influence their choice of a contraceptive method. After choosing a contraceptive method, women interested in preventing pregnancy should receive basic information about Zika virus prevention according to their level of risk, including travel considerations, mosquito bite prevention and the use of barriers to protect against infection with partners at risk of transmitting Zika. This counseling is recommended for all women, given that those using contraception may experience and choose to continue an unintended pregnancy, and that women's feelings about future pregnancy and their related contraceptive behaviors may change. This is particularly important for those choosing a less effective method, who will be at increased risk of a pregnancy.

Women who desire pregnancy, or are ambivalent or unsure and not interested in taking steps to prevent pregnancy, should receive counseling about issues related to Zika virus transmission and prevention, including discussing the implications of travel to areas with Zika transmission on recommended timing of conception for those who do not live in areas with Zika. Counseling for women desiring conception who live in areas with Zika should include discussing the optimal timing of attempts to conceive given women's reproductive life goals, and their risk of Zika infection, including whether their partners have recently had symptoms of Zika and their ability to use mosquito bite prevention strategies. In addition, women with potential risk for Zika should be counseled about the signs and symptoms of Zika infection (fever, rash, arthralgias or conjunctivitis), while also being informed that the majority of individuals infected with the virus do not demonstrate symptoms.

Zika counseling and education for men

The process of counseling and education about Zika for men is similar to women and should include a Zika risk assessment. All men should be given general information about the Zika virus, and those with potential exposure should be counseled about recommendations around timing of conception following an exposure with or without symptoms. Men should also be informed about recommendations to consider using condoms following exposure regardless of the use of other contraceptives, in order to reduce the risk of sexual transmission.

Testing for Zika

An additional role for family planning providers caring for individuals exposed to Zika is to offer and facilitate Zika testing in men and women who experienced symptoms of Zika virus infection within 2 weeks of an exposure, according to CDC guidelines [[8], [9]]. Of note, the CDC does not recommend testing of asymptomatic individuals who are not pregnant, as a negative test result can be falsely reassuring.

How to get the Zika toolkit

The OPA toolkit can be found at www.hhs.gov/opa/. This document will be continuously updated to reflect the most up-to-date understanding of and recommendations for care related to Zika for nonpregnant women and men. In addition, the CDC maintains a web-based repository of guidance and materials related to the Zika virus which can be accessed at www.cdc.gov/zika. Providers and health care administrators interested in engaging with others about best practices for family planning care in the context of Zika can join the OPA Zika Community of Practice to share additional resources and participate in online discussions (http://fpntc.org/cop/zika-virus).

What you can do to limit the impact of Zika

Zika poses a serious threat to the reproductive health of women and men in the United States and its territories, and should serve as a “call to action” for all providers of family planning services. Although there is a need to respond to Zika on an emergency basis, this also provides a remarkable opportunity to solidify and reinforce recent advances in the delivery of family planning services, so that there is a more sustained and widespread impact. We encourage family planning providers to actively work to incorporate consideration of Zika into their counseling around pregnancy, contraception and prevention of sexually transmitted infections. The unusual nature of this threat to reproductive health, as well as the lag time between infection with the virus and visual evidence of its effect on a newborn, has the potential to result in inaction when in fact family planning care may have the most potential to prevent negative outcomes associated with Zika. We must work to ensure that all women and men have the education and support they need to make informed decisions about their reproductive health, including how Zika may personally impact them and their families.

References

  1. Petersen, LR, Jamieson, DJ, Powers, AM, and Honein, MA. Zika virus. N Engl J Med. 2016; 374: 1552–1563
  2. Rasmussen, SA, Jamieson, DJ, Honein, MA, and Petersen, LR. Zika virus and birth defects—reviewing the evidence for causality. N Engl J Med. 2016; 374: 1981–1987
  3. Prevention of sexual transmission of Zika virus interim guidance. WHO,; 2016 ([at http://www.who.int/csr/resources/publications/zika/sexual-transmission-prevention/en/)
  4. Tavernise, S. W.H.O. Recommends contraception in countries with Zika virus. in: The New York times.; February 19, 2016
  5. Chaillet, N, Dube, E, Dugas, M, Audibert, F, Tourigny, C, Fraser, WD et al. Evidence-based strategies for implementing guidelines in obstetrics: a systematic review. Obstet Gynecol. 2006; 108: 1234–1245
  6. Grol, R and Grimshaw, J. From best evidence to best practice: effective implementation of change in patients' care. Lancet. 2003; 362: 1225–1230
  7. Gavin, L, Moskosky, S, Carter, M, Curtis, K, Glass, E, Godfrey, E et al. Providing quality family planning services: recommendations of CDC and the U.S. Office of Population Affairs. MMWR Recomm Rep. 2014; 63: 1–54
  8. Oster, AM, Brooks, JT, Stryker, JE, Kachur, RE, Mead, P, Pesik, NT et al. Update: interim guidance for prevention of sexual transmission of Zika virus — United States, 2016. MMWR Morb Mortal Wkly Rep. 2016; 65: 323–325
  9. Petersen, EE, Polen, KN, Meaney-Delman, D, Ellington, SR, Oduyebo, T, Cohn, A et al. Update: interim guidance for health care providers caring for women of reproductive age with possible Zika virus exposure — United States, 2016. MMWR Morb Mortal Wkly Rep. 2016; 65: 315–322