Impact of the Zika Contraception Access Network (Z-CAN) for Women in Puerto Rico Highlighted in The Lancet Public Health

In 2016 during the Zika virus outbreak, Puerto Rico had the highest number of Zika infections in the United States, a high rate of unintended pregnancy and limited access to contraception, including long-acting reversible contraception (LARC), like intrauterine devices and contraceptive implants. Today, The Lancet Public Health published an article examining the initial results of the Zika Contraception Access Network (Z-CAN), one of the strategies established to prevent Zika-related birth defects in Puerto Rico. The article reports that Z-CAN provided services to more than 21,000 women on the island between May 2016 and mid-August 2017 and demonstrated the feasibility of implementing a program to increase access to the full range of reversible contraception within a complex public health response.

Prevention of unintended pregnancy was identified as a primary strategy to reduce adverse Zika-related pregnancy and birth outcomes by the Centers for Disease Control and Prevention (CDC) early in the Zika outbreak. An April 2016 CDC report estimated that 65 percent of pregnancies in Puerto Rico were unintended and approximately 138,000 women were at risk for unintended pregnancy. The report also highlighted that contraception access in Puerto Rico was limited by reduced availability of the full range of reversible methods, high out-of-pocket costs, insufficient provider reimbursement, logistical barriers that limited same-day services, lack of patient education, and a shortage of providers trained in insertion, removal and management of LARCs.

Recognizing the importance of contraception access during the Zika outbreak, the CDC Foundation, with technical assistance from CDC and in collaboration with a diverse group of stakeholders and private donors, established Z-CAN in Puerto Rico in 2016. Z-CAN used contraception as a medical countermeasure to reduce the number of poor pregnancy and birth outcomes associated with Zika infection during pregnancy by preventing unintended pregnancy among women who chose to delay or avoid pregnancy.

“We are very pleased with the impact of Z-CAN and extremely grateful to all the donors and partners who quickly stepped forward to support the program during the Zika outbreak in Puerto Rico,” said Judith Monroe, MD, president and CEO of the CDC Foundation. “Strong partnerships from government, philanthropic, health and corporate sectors were essential to the success of Z-CAN and helped to protect more women in Puerto Rico, thereby reducing Zika-related birth defects.”

For the Zika response, Z-CAN rapidly established a network of physicians at clinics across Puerto Rico trained to provide the full range of FDA-approved reversible contraceptive methods at no cost to women who chose to delay or avoid a pregnancy during the Zika outbreak. The program also included a health communications campaign, titled Ante la Duda, Pregunta, to engage women and make them aware of Z-CAN.

Among the findings highlighted in the article are:

• Z-CAN was a short-term response for rapid implementation of reversible contraceptive services in a complex emergency setting in Puerto Rico. This model could be replicated or adapted as part of future emergency response efforts.
• The program served more than 21,000 women from May 2016 to mid-August 2017. (The CDC Foundation estimates Z-CAN in total served more than 27,000 women before ending in September 2017.)
• Z-CAN increased physician and staff capacity in contraception knowledge, counseling and initiation, as well as management of contraceptive methods, including insertion and removal of LARCs.
• Over two-thirds of women (67.5 percent) chose and received a LARC method; 24.9 percent chose either oral contraceptive pills, the transdermal patch, the vaginal ring, or depo medroxyprogesterone acetate injection; 2.9 percent chose condoms alone; and 4.5 percent did not receive a contraceptive method.

“Z-CAN demonstrates that it is possible to rapidly design, implement and scale a high-quality contraception intervention as part of a response to a public health emergency,” said Eva Lathrop, MD, MPH, an associate professor of gynecology and obstetrics at Emory University School of Medicine who is the lead author of the article and was also the deputy for contraception on the Pregnancy and Birth Defects Task Force during CDC’s Zika virus response efforts. “This feasibility program took place in one U.S. territory; the data and lessons learned here could help apply quick action in other public health emergencies.” 

The success of Z-CAN was driven by the close coordination between partners, including the Puerto Rico Department of Health; the Puerto Rico Primary Care Association; relevant federal agencies, particularly CDC; the physicians and staff participating in Z-CAN and the CDC Foundation. In addition, the CDC Foundation secured large-scale donations of contraceptive products and services from a variety of companies and organizations, including Bayer, Allergan, Church & Dwight, Americares and Janssen Pharmaceuticals, Inc., Medicines360, Merck & Co., Inc., Pfizer, Mylan, Teva Pharmaceuticals, RB, The National Campaign to Prevent Teen and Unplanned Pregnancy, Upstream USA, and MarketVision, Culture Inspired Marketing. Funding for Z-CAN was provided by the American College of Obstetricians and Gynecologists, the Bill & Melinda Gates Foundation, Bloomberg Philanthropies, Pfizer Foundation and The William and Flora Hewlett Foundation.

“The Z-CAN program changed how medicine is practiced in Puerto Rico, providing contraceptive access, information and counseling to thousands of women on the island,” said Gladysmaria Figueroa Rubero, MD, a practicing obstetrician and gynecologist in Puerto Rico and a Z-CAN provider. “For the first time, I was able to offer patients the best contraceptive options without concern about cost or availability. We empowered women and made a healthier Puerto Rico.”