Women's reluctance for pregnancy: Experiences and perceptions of Zika virus in Medellin, Colombia

Abstract Objective To explore how being infected with the Zika virus during pregnancy was experienced by affected women, and how it influenced their family relationships and future family planning. Methods We conducted a qualitative study, including 19 semistructured interviews with women of reproductive age and confirmed Zika infection during 2015–2018 in Medellin, Colombia. Purposeful sampling was applied, and participants were identified through National Public Health Surveillance System records. Interviews were recorded, transcribed verbatim, and analyzed using content analysis with inductive and deductive approaches. Results Of 19 women interviewed, eight women identified the pregnancy as unexpected and two women had undergone permanent sterilization. Women had mixed views about decision‐making related to family planning, and not having an abortion in a future pregnancy was influenced by religious beliefs. Women knew about vector‐borne transmission but were not well informed about sexual transmission of the virus. Women desired better support and guidance to ease concerns about Zika virus. Conclusion All interviewed women expressed a need for more information about Zika virus and continuous support, specifically after delivery, from healthcare professionals. Communication strategies to enhance culturally sensitive messages and for accurate perception of information are recommended during Zika outbreaks.

in the fetus. 2,3 Microcephaly is a birth defect where the baby has a smaller head compared with other babies of the same age and sex.
CZS is not limited to brain atrophy and asymmetry; it may also include abnormally formed or absent brain structures, eye abnormalities such as retinal lesions, as well as other anomalies such as excessive and redundant scalp skin. 4 The Zika outbreak in Colombia officially began in October 2015 when nine cases were confirmed by laboratory tests. 5 The number of incident cases peaked in February 2016 when more than 6000 cases per week were reported in Colombia. 6,7 With over 100 000 confirmed or suspected cases of Zika virus, Colombia has had the second largest number of reported cases in the world, after Brazil. Between 2016 and 2018, nearly 400 children were diagnosed with microcephaly in the country, 8,9 but there may be more cases of CZS that are unaccounted for in Colombia's surveillance system.
Zika virus is transmitted predominantly through the bite of infected Aedes aegypti mosquitoes, which also transmit dengue, chikungunya, and yellow fever. 10 Community programs for disease prevention in Colombia have been focusing primarily on mosquito control, such as to eradicate or control mosquito breeding areas. 11 However, Zika virus can also be transmitted during pregnancy from a woman to her fetus, and through unprotected sexual activity. 12 A study in Brazil found high general awareness of the Zika virus, while women's knowledge about sexual transmission was low. 13 The fact that this mosquito-borne virus can also be transmitted through sexual contact makes it a unique public health challenge, adding to the risk of Zika infection among women.
The Zika virus outbreak highlighted barriers to sexual and reproductive health and rights (SRHR) in Latin American countries, such as Brazil and Colombia, including restrictive sexual and reproductive health (SRH) policies and reduced access to SRH services. In 2006, Colombia decriminalized abortion only under exceptional circumstances, including life-threatening maternal conditions and severe fetal brain malformations, such as those seen in CZS. 14 The cost of different family planning methods can act as an economic burden and access to SRH services is a challenge in Colombia; particularly for women on low incomes living in remote and rural areas owing to lengthy travel distances to clinics. 6 Previous research in Brazil has identified health system shortcomings in adequately protecting children with disabilities associated with CZS, and that conservative gender norms and gender inequalities seriously limit access to SRH services. 15 To improve prevention and management of Zika virus infection, the aim of the present study was to understand the perceptions among women of reproductive age who had been infected with Zika, the impact on their families, and their reproductive choices and plans.

| MATERIALS AND METHODS
A qualitative approach using content analysis was considered appropriate for our study to understand women's experience of being infected with Zika virus during pregnancy, concerns about CZS, and perceptions on family planning.  (6) able and willing to give informed consent as well as understand and comply with the study. We excluded women who were travelers/visitors not from Colombia and non-Spanish speakers, as well as those with reported co-infections. During October 2015 to April 2018, a total of 297 women infected with Zika virus-including 113 pregnant women-were reported to SIVIGILA. Nineteen women who met the inclusion criteria were invited to participate in the interview, and all of them agreed.
After establishing formal permission to conduct the study from the Secretariat of Health in Medellin, informed consent was provided over the telephone from women who were registered as a confirmed case of Zika infection and whose baby was suspected to have CZS.
We informed the potential participants about the study objectives and goals, the voluntary aspects of participating in the interview, potential risks and measures taken to prevent those risks, as well as the mode of the participation for the face-to-face interview. After we had obtained written consent, the participants were still able to withdraw at any point during the face-to-face interview without any negative consequences for their healthcare services.
Participants were asked if they preferred a male or a female interviewer and if there was a preference in the location of the interview, as we wanted them to feel comfortable. To facilitate attendance, we provided reimbursements for any transportation costs. Semistructured interview was chosen as the method of data collection. The research team constructed and piloted an interview guide with questions in Spanish, probing areas under topics related to awareness of Zika virus and means of information, experiences during the pregnancy and family planning in relation to abortion, as well as experiences surrounding healthcare staff and core support system (supporting information Data S1). The interviewers considered the nature of sensitive topics during the interviews and allowed the participants adequate time to reflect and respond, and they were also ready to clarify any points of uncertainty about Zika as necessary. All interviews were performed in Spanish by either VT or SAMM and BNRJ, who observed each of the interviewees' reactions and gestures. Interview duration was between 40 and 60 minutes.
Interviews were conducted until saturation was reached and further data collection did not contribute to new information on the main topics.
The interviews were recorded and transcribed verbatim, and only the research team had access to the data. The researchers preserved the anonymity and confidentiality of the women who were interviewed, and conducted the data analysis with replaced names, along with all identifiable information. In accordance with Graneheim and Lundman, 17 Figure S1). The deductive approach allowed us to emphasize the general subcategories, while the inductive approach focused on new codes and meaning units.
The final categories were generated using an inductive approach in English to consolidate the original categories using Excel (Microsoft; Redmond WA, USA). An example of a trail analysis is shown in supporting information Figure S2.
We considered several aspects to improve the trustworthiness of our research. The researchers recognized the possibility of respondent bias and this might have resulted in biased interpretations. Parts of the interview material were initially coded by SAMM and then compared by VT ensuring codes were derived from the raw data in an attempt to mitigate researcher bias. If discrepancies were encountered, they were discussed within the research team, and the differences in coding were discussed until the interpretation could be agreed by all.
Revisions were conducted on the primary data and during the analysis and writing process by continuous discussions among the research team. Other ethical principles, such as confidentiality and anonymity of research participant, were applied.

| RESULTS
We conducted 19 semistructured interviews with women diagnosed with the Zika virus during pregnancy, including three women who had children with adverse physical outcomes, including microcephaly, brain atrophy, and arthrogryposis. There were no follow-up interviews. The sociodemographic characteristics of the participants are shown in Table 1. The women reported that their diagnosis of Zika virus had occurred mainly during the third trimester of pregnancy (from week 27 to the end of the pregnancy). All 19 women had given birth to a child that was suspected to have CZS. The ages of the women varied between 18 and 38 years. Six women were single and two women were separated, while eight had long-term partners and three were married. All interviews were conducted in Medellin, Colombia.  Table 2.

| Knowledge about Zika virus
All 19 women had previously heard about Zika virus and knew where to find additional information. The women mentioned several sources of information about the virus, such as television or radio, from T A B L E 1 Sociodemographic characteristics of the 19 women interviewed.

Characteristics
No.
Age, y

Educational level
Higher/university 4 Higher/non-university 6 Secondary education 8

Primary education 1
Socioeconomic status a

Lower-class (estrato 1-2) 14
Middle-class (estrato 3-4) 5 Occupation Employed 9 Unemployed 9 Student (not employed) healthcare professionals or doctors, and attending workshops in their community or school seminars. The women indicated that they were familiar with the different mosquito-borne diseases, and the true impact of dengue or chikungunya was better understood when people in their communities or close friends had experienced such disease.

| Concerns about Zika virus
The immediate emotional response mentioned by the participants was concern about the possible Zika-related health complications during

| Accuracy of information received about Zika virus
Information provided by different media sources and healthcare professionals about Zika virus was perceived as inaccurate by the participants. Despite being a registered case of Zika virus, many of the women were given another diagnosis other than Zika virus, which resulted in a late or unclear diagnosis. One woman said: I had Zika and chikungunya tests, but at the time, it was also dengue… I did not know I had Zika, they said I probably had dengue and they would call, but they never called me. The women did not report signs of mental health disorders.
However, much of the necessary healthcare support described by More subtle but still significant is the impact of the disease during pregnancy and the unknown long-term effects of the virus, which seem to influence decision-making on family planning. SRHR regulations in Colombia aim to prevent unwanted pregnancies, and do not require parental consent for SRH counseling or access to contraception. 24 We found that some of the women interviewed desired a future pregnancy, but others expressed unwillingness for another pregnancy and child- In conclusion, this study explored the experiences and perceptions of Zika virus among women during their pregnancy. Further research is recommended to explore the impact of Zika virus on the uptake of family planning services, unmet needs from these services, and the role of male involvement in women's sexual and reproductive health.
In addition, the sources of information, such as health authorities and governmental sources, should work to ensure provision of clear and unambiguous recommendations and advice that is culturally sensitive to stress the key messages in the context of Zika virus.

AUTHOR CONTRIBUTIONS
All authors contributed to the planning and proposal of the research project. VT, SAMM, and BNRJ conducted the data collection, analysis, and writing of the original report. All authors contributed to reviewing drafts of the paper. All authors read and approved the final manuscript.

CONFLICTS OF INTEREST
The authors have no conflicts of interest.

SUPPORTING INFORMATION
Additional supporting information may be found online in the Supporting Information section at the end of the article.