Sean Philpott-Jones: The Growing Perils Of Pauline’s Pregnancy

Jan 28, 2016

It’s not easy to be a mother these days. Despite all of the advances in gender equality, the rearing of children still remains by default “women’s work.” This is not to say that fathers are not increasingly involved in caring for their kids, but most studies have shown that women still do the bulk of the work. Not only do they have to put up with nine months of discomfort while pregnant, once the child comes mothers are more likely than fathers to be responsible for changing diapers, looking after a sick kid, arranging for daycare and play dates, and even cooking, cleaning, laundry and other household chores.

You can now add to this some new fears: post-partum depression and the Zika virus. Earlier this week, for example, the US Preventive Services Task Force – an independent and non-partisan group of healthcare experts – recommended that all pregnant women and new mothers be screened for clinical depression. Despite several decades’ worth of research showing that a significant percentage of pregnant women and new mothers (nearly 1 in 10) will experience a major depressive episode, it goes largely undiagnosed. Untreated depression is the leading cause of prenatal and maternal morbidity in the US, and is associated with an increased risk of substance abuse and suicidal ideation among new mothers.

Given the Preventive Services Task Force new recommendations on depression, it is likely that most health insurance companies will soon cover the costs of screening. It may also spur Congress to pass legislation, introduced last year, which would fully fund mental health screening and treatment for all pregnant women and new mothers. Treatment, however, will likely remain a contentious issue.

Even when pre- or post-partum depression is diagnosed, whether because of perceptive doctors, the concern of family members, or a known history of mental illness, many afflicted women go still untreated. This is in part because antidepressant drugs – particularly the family of medications known as selective serotonin reuptake inhibitors (SSRIs), a class of drugs that includes such popular medicines as Paxil, Prozac, and Zoloft – have been linked to miscarriage, premature birth, low birth weight, birth defects and, in one small and still controversial study, autism. Although the absolute risk of these adverse birth outcomes is small, it is not insignificant, leaving many mothers and their physicians with the difficult challenge of weighing the known risks of untreated depression with the potential harms to the unborn child.

If that wasn’t enough to make some think twice about having a child, pregnant women worldwide must now worry about a mosquito-borne virus known as Zika. Although the virus was first discovered nearly 70 years ago in African monkeys, there have been almost no cases of human infection until recently. The first known outbreak occurred in Micronesia in 2007, followed by an outbreak in French Polynesia in 2013. However, these outbreaks didn’t raise any real concerns among doctors and public health officials, because of number of people infected was small and the symptoms relatively benign. In fact, over three-fourths of people infected with Zika don’t experience any clinical symptoms at all. Those who do become sick tend to develop a fever, headache and joint and muscle pain, but the symptoms are relatively mild and resolve within seven days.

So why is concern growing about the Zika virus now, especially for pregnant women? Starting in early 2015, public health officials in Brazil reported an outbreak of Zika in the northern part of that country. Within a short period of time, the virus spread to 21 other countries in the Americas. This includes the United States, where 20 cases of Zika have been reported among people who have traveled to Brazil or elsewhere in Central and South America.

Shortly thereafter, Brazilian authorities noted a sharp increase in the number of cases of a birth defect known as microcephaly, a rare neurological condition in which an infant is born with a smaller-than-usual brain. While some children born with microcephaly develop normally, many will experience lifelong symptoms including developmental delays and disabilities, difficulties with coordination and movement, hyperactivity, and seizures.

Since the outbreak began in Brazil, that country has reported nearly 4,000 suspected cases of microcephaly. In the previous year, the number of cases was less than 150. Although a casual link between Zika and microcephaly has not yet been proven, data now suggest that the risk of having an afflicted child increases 30-fold if a woman is infected with the virus while pregnant. So alarming are these figures that the US Centers for Disease Control and Prevention (CDC) has advised pregnant women to postpone travel to regions of the world where Zika outbreaks are actively occurring. Similarly, government officials in El Salvador, Columbia, Jamaica and Ecuador have taken the unprecedented step of recommending that women in those countries avoid getting pregnant until the Zika outbreak is contained.

Even if you are not planning to travel to Rio for the Olympic Games, however, you have reason to be concerned. The mosquito that transmits Zika is already present in the United States. Moreover, the warm and wet winter caused by this year’s El Niño event make it likely that these mosquitos will thrive in the coming months. That, coupled with the likelihood of the virus continuing to enter the United States with ever increasing trade and travel with Latin America, means that Zika will likely take root in our fertile American soil. All we can do now is wait, plan and hope that a safe and effective vaccine for Zika is developed soon.

A public health researcher and ethicist by training, Dr. Sean Philpott-Jones is Director of the Bioethics Program at Union Graduate College-Icahn School of Medicine at Mount Sinai in Schenectady, New York. He is also Director of Union Graduate College's Center for Bioethics and Clinical Leadership, and Project Director of its two NIH-funded research ethics training programs in Central and Eastern Europe and in the Caribbean Basin.

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