CAGUAS, Puerto Rico — Before the virus overwhelmed Puerto Rico, Zika already lurked in Keishla Mojica’s home.
First her partner, John Rodríguez, 23, became infected. His face swelled and a red, itchy rash covered his body. Doctors at the time diagnosed it as an allergy.
Two months later, Mojica, 23, had the same symptoms. Medics administered shots of Benadryl to soothe the rash and inflammation. She didn’t give it much more thought.
A month later she also found out she was pregnant, and that eventually led to a surprising revelation. The rashes hadn’t been caused by allergies, but instead by Zika, a virus known to cause serious birth defects.
Since 2015, the virus, which is spread by mosquitoes and sexual contact, has risen from relative obscurity to a worldwide menace. Puerto Rico marks the epicenter of the outbreak in the United States. As of Dec. 16, the commonwealth’s health department reported 35,648 confirmed cases, including 2,864 pregnant women. Federal health officials have declared a public health emergency here and anticipate 25 percent of the population will have contracted the virus by the end of 2016.
The epidemic raises difficult personal questions for women like Mojica, who live on an island with strong religious undercurrents and a health care infrastructure bowing under the weight of fiscal debt. Is abortion acceptable or can faith overcome the fear? If a baby is born with disabilities like microcephaly, characterized by an abnormally small head, or cognitive impairments, how will families provide the care a child will need?
A sonogram taken in August 2016 at HIMA San Pablo Hospital in Caguas, Puerto Rico, reveals a healthy baby boy inside Keishla Mojica, 23. Doctors initially feared his small size indicated a Zika infection, but they later learned Mojica became pregnant later than previously thought. (Carmen Heredia Rodriguez/KHN)
In response to the association between congenital defects and the virus, virtually all pregnant women on the island undergo testing for Zika as part of their prenatal care. Dr. Alfonso Serrano, 57, chairman of the obstetrics and gynecology department at HIMA San Pablo Hospital in Caguas and Mojica’s doctor, said the testing has shown that 5 to 8 percent of his patients contracted Zika.
Even though the threat of Zika frightens women, he said, most of his patients don’t consider abortion.
“It’s not something that is talked about every day,” he added.
Serrano attributes the aversion to terminating a pregnancy as more of a cultural idiosyncrasy than particularly devout faith. Abortion is easy to obtain here and relatively inexpensive, but surveys show that an overwhelming majority of residents said they oppose the practice.
For Mojica, abortion was the first thought that crossed her mind when she heard she had been infected. She told no one but her mother and Rodríguez about the diagnosis. She cried and prayed often. Public service announcements on television about the outbreak angered her. But Mojica never actually discussed the possibility of an abortion with anyone, and she realized quickly that she couldn’t choose that option.
“I waited until they gave me the results and that they verified everything,” she said. But Mojica added that she quickly put aside any thoughts about abortion. “I said, ‘No, forget it. Everything’s fine. Forget about it.’ That was in the moment.”
Religious Objections To Abortion
The echoes of Roman Catholicism introduced by Spanish colonial rule still reverberate through contemporary Puerto Rican society. Ninety-nine percent of its residents believe in God. Children greet their elders by asking for a benediction, to which they reply, “Dios te bendiga” — “May God bless you.”
Planificacion Familiar, an abortion clinic operating out of the corner unit of a strip mall in Bayamon, Puerto Rico, is run by Dr. Hector Diaz, 86. Diaz says he administers surgical and medical abortions, charging between $250 to $300 for the full procedure and follow-up appointment. (Carmen Heredia Rodriguez/KHN)
But the church’s influence is declining. Just over half of the population self-identifies as Catholic, according to a 2014 Pew Research Center survey. In contrast, the number of Protestants has surged, now comprising a third of residents.
Puerto Ricans and religious leaders generally don’t support abortion. More than 70 percent of Catholics and eight out of 10 Protestants on the island morally oppose the procedure, according to Pew.
In February, the Catholic Archbishop of San Juan released a statement responding to the health department’s advisory to use condoms as part of preventing Zika transmission. The church’s stance against birth control are “well-known,” he said, encouraging couples to practice “personal discipline,” or abstinence from sex.
The Pentecostal Fraternity of Puerto Rico (FRAPE) — a network of Pentecostal churches across the island — also view their opposition to abortion as a non-negotiable tenet.
“God is the giver of life,” said FRAPE president Alberto Rodríguez. “And he has absolute control to take it or give it.”
Although rates have declined in recent years, thousands of women in Puerto Rico continue accessing abortion services. Seven of the island’s eight clinics performed 5,363 abortions in the fiscal year starting July 2013, based on the most recent data available from the commonwealth’s health department. More than 2,000 had undergone one other abortion. And roughly 1,350 women had sought two or more procedures.
Mojica was a faithful member of a Seventh-day Adventist congregation — which does allow for abortion in cases of certain congenital abnormalities — but says she now converses with God on her own.
Resources Available For Kids with Disabilities
Recent research suggests that Zika causes a wider range of congenital problems that previously suspected. And with a quarter of Puerto Rico’s residents thought to be infected, it is unclear how many babies will have special needs. But finding adequate care for children born with disabilities is difficult in Puerto Rico, where services are fragmented, poorly funded and already oversubscribed. Nearly half the population lives in poverty.
A nurse holds a vial with a camouflaged stopper that is used to collect blood specimens from newborns whose mothers were infected with Zika during their pregnancy at HIMA San Pablo Hospital in Caguas, Puerto Rico in November 2016. (Carmen Heredia Rodriguez/KHN)
The Division of Children with Special Medical Needs, part of the commonwealth’s health department, runs some programs to assist families with children with disabilities, such as Advancing Together, a service that trains caregivers and helps families set up a development plan for the child. But the program expires when the child turns three, and responsibility for services is transferred to the Puerto Rican Department of Education, which has consolidated or closed dozens of schools in recent years due to declining enrollment rates and strapped budgets. Thirty percent of students attending public schools on the island in 2013 were enrolled in individualized education programs.
Nonprofit groups also play a role in helping children with special needs, such as Support for Parents of Children with Impediments and the Muscular Dystrophy Association. Yet, therapy services available are extremely limited, said Miguel Valencia, director of the Division of Children with Special Medical Needs. Although half the island’s residents rely on Medicaid for health insurance, Valencia said, many specialized clinicians no longer accept the plan due to low reimbursement rates.
Puerto Rican residents do not qualify for Social Security Administration’s Supplemental Security Income program, which provides assistance if a medical condition results in severe disability, chronic illness or death. The service is limited to individuals living in the 50 states, the District of Columbia and the Mariana Islands.
A small figurine of a boat sits on a shelf in the nursery of Mojica and John Rodriguez in Mojica’s mother’s home in November 2016 in Caguas, Puerto Rico. The couple settled on the room’s decoration after a compromise between the couple; Rodriguez chose the theme for the baby shower, Mojica the theme for the nursery. (Carmen Heredia Rodriguez/KHN)
Waiting For Jayden
Among the pixels of black and shades of orange, the ultrasound image shows the outline of a human face with his eyes closed directly facing the camera. It appears modulated, akin to a half finished piece of pottery. The five stubby fingers of his right hand are pressed against his forehead as if he is lost in contemplation.
It is a sonogram, one of the first portraits of Mojica’s son, who she plans to name Jayden Aramick.
The nursery overflows with outfits in anticipation of his arrival early this year. Black Converse booties and Batman onesies hang in the armoire. Wooden letters spell his name on the wall above the crib.
Although the baby continues to grow without complications or signs of microcephaly, Mojica’s son still faces possible developmental delays from the virus that could develop after he arrives. But at this point, the risk no longer weighs on her conscience. She has given her worries to God.
“What He says is what will come to be,” she said.
This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.