Disease, Fertility, and Inequity

In Brazil, the consecutive health crises of Zika and COVID-19 have created challenging circumstances for family planning. Even years after the COVID pandemic, Letícia Marteleto, Presidential Penn Compact Professor of Sociology, says “scars” linger from those ordeals, with long-reaching implications for fertility and reproductive decision-making.

Marteleto, who is originally from Brazil, has been closely monitoring how living through Zika and COVID has influenced behaviors and the decisions that women make around fertility. She’s doing that through a project called Decode Zika and COVID (DZC), which is about to kick off a fourth “wave” of data collection, buoyed by a grant renewal from the Eunice Kennedy Shriver National Institute of Child Health and Human Development at the National Institutes of Health (NICHD), a competitive grant awarded to just 2 percent of projects.

DZC first began in 2017, focused solely on Zika, and quickly expanded to include COVID. The project’s first three phases captured interviews with some 4,000 women, documenting how Zika—and subsequently COVID—affected them and their children, as well as their reproductive lives and their intentions to have more children.

Those interviews revealed a wide range of behavioral changes. Women affected by Zika, for example, were more likely to change their minds about wanting to have children during the COVID pandemic. On the flip side, exposure to COVID, including COVID-related deaths, made some women want to have more children.

Marteleto says she hopes the fourth wave of data collection will shine more light on how those processes unfold throughout women’s lives, especially for those in areas where Zika and COVID rates were higher. “With this new phase, we want to understand the way experience with back-to-back disease crises affects how women approach their reproductive lives,” Marteleto says. “We really want to get a sense of how these experiences have major implications for their lives and decisions, as well as for reproductive equity.”

Adapting Amid Crisis

Getting to this stage of research has meant constantly responding to a rapidly shifting public health landscape. Prior to the onset of COVID, Marteleto, then a sociology professor at the University of Texas at Austin, was leading a team of interviewers, supervisors, and data analysts focused on the Brazilian state of Pernambuco, an area hard hit by Zika between 2015 and 2017. Though the mosquito-borne virus is often mild for adults, it can pass from pregnant people to fetuses, leading to severe birth defects. Those include microcephaly, a condition that shrinks head size, often affecting brain development.

Image

Zika affected more than 3,700 babies in Brazil, leaving many with birth defects, while also spreading widespread global concern around reproduction. Within this context, Marteleto was studying how the crisis had influenced the way women thought about fertility, including whether to have children and whether they could access birth control and other resources. When COVID kicked off, Marteleto’s team migrated from in-person to phone interviews—and from being Decode Zika to Decode Zika and COVID.

As COVID ramped up, the team observed how lingering Zika anxiety influenced the women they spoke with, with many deciding to delay or forego pregnancy altogether, often due to negative experiences with Zika. But those decisions also varied based on factors like race and class, with DZC’s data showing that lower-income and Black women were less likely to have access to resources like birth control and other family-planning methods.

Another notable data point was just how strongly previous heightened Zika exposure seems to have steered desires as COVID worsened. DZC found that some women affected by Zika, for instance, were more likely to express that they wanted sterilization during the subsequent pandemic, signaling just how concerned they were about COVID. Still others felt a greater desire to expand their families, citing exposure to pandemic-related deaths as the impetus.

“A Huge Difference”

Five years later, DZC’s work is far from over, and Marteleto says coming to Penn has been a game changer.

Since joining Penn Arts & Sciences, she’s been hard at work, serving as a research affiliate of the Population Studies Center (PSC) and rapidly expanding her team. “Penn attracts the most brilliant and accomplished students,” she says, noting the project has already drawn several graduate and undergraduate students, as well as postdoctoral scholars. “This has made a huge difference.”

Another graduate student will join the project next year, Marteleto says, and she has secured internal funds to add two more undergraduates as well. She also credits the sociology department, along with the PSC and the College, where colleagues have shown “a great deal of interest in the project.” Her overarching goal, she adds, is to foster collaboration among people at Penn interested in the social aspects of reproductive health and fertility.

The conversations she’s having are already leading to new ideas that build on her current work. Brazil has recently experienced an onslaught of flooding, followed by dengue hemorrhagic fever, which has led Marteleto to wonder about how extreme weather events and new epidemics might further compound reproductive health outcomes and deepen social inequities in reproductive trajectories.

We want to understand the way experience with back-to-back disease crises affects how women approach their reproductive lives. We really want to get a sense of how these experiences have major implications for their lives and decisions, as well as for reproductive equity.

Marteleto thinks of DZC’s work in Brazil as part of a bigger story, one that keeps growing. The United Nations has already warned of the possibility of additional epidemics and pandemics in the future. Brazil is a vast country with deep inequities, much like the United States, Marteleto says, and the data DZC are gathering could be vital to understanding how similar reproductive trends might unfold elsewhere.

“Brazil can serve as a case study,” she says. “It’s so important for understanding how we handle the next crisis in terms of preparedness and implications for women’s reproductive lives. It’s critical to see how these things unfold.”

For example, Marteleto says, the team wants to study connections between the desired number of births and their timing for women who experienced an epidemic earlier in their reproductive lives versus later. Those will be important questions, she adds, because most countries in the Americas—Brazil and the U.S. included—have fertility rates below what’s needed for a population to remain stable, what’s known as the fertility “replacement level.”

The funding Marteleto’s team recently received will cover five more years of work, beginning this spring. DZC plans to add 2,000 more women to its panel, launching two waves of outreach each year through 2027. That will entail everything from sending letters to participants in hard-to-reach areas to sending WhatsApp messages and posting on Instagram in both English and Portuguese.

“We want respondents to be able to learn more about the project and continue to be in touch,” says Marteleto. “Equally important is taking a decolonial approach to science. We don’t want to reproduce a model in which scholars from the Global North collect data on the Global South, only for the final products to just be in English.”

Those considerations helped make the project competitive for grants, but Marteleto acknowledges the ongoing uncertainty around government funding. With many grants now under government review, Marteleto knows it’s possible DZC’s funding could, in theory, end after June.

“If for any reason these funds are cut despite having been approved, it would jeopardize the entire project and take away an opportunity we’ll never have again to capture this data,” she says, noting it took her almost a decade to assemble a high-quality international team capable of executing the endeavor. “Not even COVID-19 stopped us before. If this did, the loss would be immeasurable.”